Transcript Water in New Hampshire

Board of Directors
William H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Daniel Wolf
Martin L. Gross, Chair
Emeritus
Directors Emeritus
Aging, Managed Care
and the Long Term
Care System
Managed Care Commission
Sheila T. Francoeur
Stuart V. Smith, Jr.
Donna Sytek
May 1, 2014
Brian F. Walsh
Kimon S. Zachos
“…to raise new ideas and improve policy debates through quality
information and analysis on issues shaping New Hampshire’s future.”
1
Topics to Consider
• NH Ages
• Shifts in Medicaid Spending
• Managing the care of an elderly
person with complex needs is …
complex.
• What can we learn from phase 1
implementation?
• What kind of program do you want?
• What about the counties?
2
Aging is a complicated story
here in New Hampshire
3
Are we old? Not yet, but
getting there …
T h e L a rg e s t Im p a c t o f A g in g w ill o c c u r a fte r 2 0 2 0
3 0 0 ,0 0 0
20%
18%
P o p u la tio n A g e 7 5 +
2 4 7 ,7 4 0
2 5 0 ,0 0 0
16%
2 1 6 ,1 5 3
% N H 's T o ta l P o p . T h a t is A g e
75+
14%
2 0 0 ,0 0 0
1 7 5 ,4 1 9
12%
1 3 8 ,4 8 4
1 5 0 ,0 0 0
10%
8%
1 0 6 ,0 8 6
1 0 0 ,0 0 0
6 9 ,6 4 3
5 3 ,1 4 7
7 5 ,3 6 0
8 1 ,5 0 6
8 8 ,4 9 4
6%
6 0 ,4 1 4
4%
5 0 ,0 0 0
2%
0
0%
1990
1995
2000
2005
2010
2015
2020
2025
2030
2035
2040
4
Geography Matters
5
Growth in the Frail Elderly
6
The
Geography
of Elderly
Poverty
7
The Aging Bubble will end
…
8
Aging Changes the Way
We will Spend
9
Currently, much of the Medicaid
spending is for those under the
age of 65 (2009)
Medicaid Spending 2009 by Age and Sex
$300,000,000
$250,000,000
$200,000,000
2010 (Women)
2010 (Men)
$150,000,000
$100,000,000
$50,000,000
$0
0-19
20-44
45-64
65-74
75 - 84
85 +
10
A very different picture
in 2030
2030 Aged 2009 Medicaid Spending by Age and Sex
$400,000,000
$350,000,000
2030 (Women)
2030 (Men)
$300,000,000
$250,000,000
$200,000,000
$150,000,000
$100,000,000
$50,000,000
$0
0-19
20-44
45-64
65-74
75 - 84
85 +
11
Shifts in Medicaid
Spending
2009 Medicaid Spending by Age
85 +
11%
75 - 84
8%
0-19
29%
2030 Aged (2010) Spending
0-19
19%
85 +
23%
65-74
6%
20-44
17%
45-64
22%
75 - 84
19%
20-44
24%
65-74
10%
45-64
12%
12
Driven by Age and Shifts in
Demand for Services
78 PRIV NON-MED
INST FOR CHILDREN
1%
2009
78 PRIV NON-MED
INST FOR CHILDREN
2%
66 HOME&COMM
BASED CARE-CI &
ELD
6%
65 HOME&COMM
BASED CARE - DI
16%
1 INPATIENT
HOSPITAL, GENERAL
6%
All Other
7%
7 OUTPATIENT
HOSPITAL, GENERAL
6%
11 SKILL NURSING
FAC NURSING HOME
1%
12 INTERMED CARE
FAC NURSE HOME
31%
45 DENTAL SERVICE
2%
43 PHYSICIANS
SERVICES
4%
15 SNF NURSING
HOME ATYPICAL
CARE
32 FURNISHED MED
0%
SUP OR DME
16 ICF NURSING
1%
HOME ATYPICAL
17 MENTAL HEALTH
30 DISPENSE
CARE
CENTER
PRESCRIBED DRUGS
0%
25 CLINIC SERVICES
8%
7%
3%
2030
1 INPATIENT
7 OUTPATIENT
HOSPITAL, GENERALHOSPITAL, GENERAL
All Other
4%
5%
6%
66 HOME&COMM
BASED CARE-CI &
ELD
8%
11 SKILL NURSING
FAC NURSING HOME
2%
65 HOME&COMM
BASED CARE - DI
13%
45 DENTAL SERVICE
1%
43 PHYSICIANS
SERVICES
3%
32 FURNISHED MED
SUP OR DME
1%
30 DISPENSE
PRESCRIBED DRUGS
5%
25 CLINIC SERVICES 17 MENTAL HEALTH
CENTER
2%
6%
12 INTERMED CARE
FAC NURSE HOME
42%
15 SNF NURSING
HOME ATYPICAL
CARE
0%
16 ICF NURSING
HOME ATYPICAL
CARE
1%
Nursing Home Care
13
Workforce Issues will
become more acute.
14
What do you mean when
you say managed care?
15
Acute
Medical
Chronic
Medical
Community
Based LTC
Assisted
Living
Nursing
Home
What does a Long-Term-Care Accountable Care
Organization Look Like?
16
Nutrition and Financial
support (2012)
• Food-stamps
– Maximum grant is about $5.80 per day per person.
Of a total 56,887 cases in July (2012), 5,944 or 5.1%
are over age 65. Of these, 1,215 have a cash grant
• Meals Programs (Title III)
– 11,454 individuals received home delivered meals.
– 17,192 received congregate meals
• TANF Grants for Lower Income Elderly
– Household size of one must be under $712 per month
and aged 65 or older; Average grant is $164.13 in
July 2012
17
Other
• Housing
– Section 8 housing?
– Other efforts
• Transportation
– Title III – provided almost 19 visits per person over
the age of 65 living in poverty in NH.
– Medicaid provides transportation services
• Acute Healthcare
– Medicaid
– Local Welfare
18
State (or county based)
Long Term Care Supports
• Public Health (support for falls, chronic
conditions for those 55 to 64)
• Medicaid Nursing Home
• Home and Community Based Care
• Title III
– Adult Day Care – 654 individuals received support
– Homemaker – 645 individuals received support
– Personal Care Services – 523 received support
19
Support and Information
•
•
•
•
Service Link (ADRC)
Legal Services
211 Calls
Managed care prior
authorization and care
coordination?
• Other ?
20
What about the impact of
the budgetary changes
from 2010 – 2013?
A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
22
23
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
B
Department of Health and Human Services
Adjustments to BEAS Budget Requests
General Funds Rounded to $000
E
F
G
H
SFY10
SFY11
SFY12
SFY13
($808)
($8,438)
($839)
$0
($853)
($751)
($514)
($324)
($259)
($250)
($166)
($105)
($130)
($1,397)
($8,606)
($1,520)
($2,000)
($879)
($766)
($575)
($330)
($259)
($260)
($166)
($119)
($130)
Rate Reduction-Contracted Services
MQIP 100% (State Retains 25%)
Redefine/clarify Rule for Personal Care Services & Homemaker Services
Raise county cap by 2% in line with inflation
Require Single Dose Medication for H.H.RN Visits
Freeze funding Congregrate Housing Supports
Discontinue Case Management to Mid-Level Care
Freeze funding ADRD & Caregiver Program
Funding from Money Follows The Person
Eliminate Catastrophic Illness Program
Reduce general funds for SSBG programs
Freeze State Funding of Service Link Program
Volunteer -Sr. Companion-Foster Grandparent
HCBC-ECI - Rebalancing Similar Services
Adjust county cap for nursing services
Reduced class 512 transportation of clients
($1,303)
($2,253)
($12)
($400)
$0
($134)
($184)
($400)
($500)
($134)
21
What Can We Learn from
Phase 1 about Phase 2?
22
NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES
BEAS PROVIDER PAYMENTS
FOR THE FIRST TWELVE MONTHS OF STATE FISCAL YEARS 2010, 2011 AND 2012
05-01-08-04-01 6173-101
Total Expenditures by Category of Service
What services
did the
Department pay
for before?
ADULT MEDICAL DAY CARE
ADVANCE REG NURSE PRACT
AMBULANCE SERVICE
AUDIOLOGY SERVICES
CHIROPRACTIC
CLINIC SERVICES
DENTAL SERVICE
FAMILY PLANNING SERVICES
FURNISHED MED SUP OR DME
HOME HEALTH SERVICES
HOME&COMM BASED CARE-CI & ELD
I/P HOSPITAL SWING BEDS, ICF
I/P HOSPITAL SWING BEDS, SNF
ICF SERVICES FOR MR
INPAT PSYCH FAC SRVS-UNDER 22
INPATIENT HOSPITAL, GENERAL
LABORATORY (PATHOLOGY)
MEDICAL SERVICES CLINIC
OCCUPATIONAL THERAPY
OPTOMETRIC SERVICES EYEGLASSES
OUTPATIENT HOSPITAL, MENTAL
PERSONAL CARE
PHYSICAL THERAPY
PHYSICIANS SERVICES
PODIATRIST SERVICES
PRIVATE DUTY NURSING
PSYCHOLOGY
RURAL HEALTH CLINIC
SKILL NURSING FAC NURSING HOME
SNF NURSING HOME ATYPICAL CARE
SPEECH THERAPY
WHEELCHAIR VAN
X-RAY SERVICES
Subtotal Category of Service
NUMBER OF INDIVIDUALS SERVED
Claims Paid First Four Quarters SFY 2012
Average
Cost per
Total
Service
Recipient
Count
Total Expenditures Recipients
$
386,695.68
5,011.62
220,814.72
3,882.60
31,201.35
58,266.00
181.39
2,099,084.90
620,515.23
48,862.49
256,706.23
148,300.74
6,792.00
3,412,973.88
17,663.12
3,096.33
542.77
93,222.65
5,176,748.24
12,100.09
1,556,569.94
34,661.63
597,156.20
27,794.36
245,107.85
5,348,053.07
7,465,435.75
275.70
2,070,659.30
24,831.64
138
166
2,407
72
0
219
164
2
2,546
451
3
24
110
2
1
1,739
156
4
12
1,634
1
149
66
6,204
1,361
7
150
957
2,946
70
2
2,394
1,515
29,973,207.47
25,672
$ 2,802.14
30.19
91.74
53.93
142.47
355.28
90.70
824.46
1,375.87
2,035.94
2,333.69
74,150.37
6,792.00
1,962.61
113.23
774.08
45.23
57.05
34,743.28
183.33
250.90
25.47
85,308.03
185.30
256.12
1,815.36
106,649.08
137.85
864.94
16.39
20,706
615
14,385
259
0
2,338
858
6
46,925
16,876
0
1,308
8,004
378
81
575,247
2,468
308
151
6,238
9
7,010
1,399
137,709
4,133
12,048
1,242
7,583
216,018
15,362
21
119,105
7,675
Average
Cost per
Service
$ 18.68
8.15
15.35
14.99
13.35
67.91
30.23
44.73
36.77
37.36
32.07
392.33
83.85
5.93
7.16
10.05
3.59
14.94
738.48
8.65
11.30
8.39
49.56
22.38
32.32
24.76
485.97
13.13
17.39
3.24
7,842
23
Prior Authorization
• Each Health Plan will have their own approach to
service authorization/prior authorization. If there
is a particular service you are curious about, the
Health Plan’s customer service line (members)
or provider relations (providers) can assist. The
DHHS is preparing a tool called the Quick
Reference Guide for providers, which will include
information on what services require a PA and
how to obtain one.
http://www.dhhs.nh.gov/ombp/caremgt/documents/provider-qa.pdf
24
Relative to care in a
nursing home ….
What services are not included in the per diem and, therefore, are the
responsibility of the Health Plans? The Health Plans are responsible
for all services not included in the per diem (see Services
Associated with the Nursing Facility Per Diem). Services not
included in the per diem, include:
•
•
•
•
•
•
•
•
•
•
•
Physician services and/or consultations
Non-emergent or emergency transportation by ambulance
Transportation by any vehicle not owned by the facility
DME – for example, a specialized, customized wheelchair
Prosthetics and orthotics
Elective admission
TPN/all infusion services
Lab services – all lab services provided by a provider other than the facility
Outpatient facility services
Pharmacy
All hospital services
25
Supporting the Transition to Managed
Care for Frail Elderly with Complex
Needs
• Care Coordinators - Providing or arranging for care coordinators to
support the primary care practices is a prominent feature across the
programs.
• Technical Assistance and Practice Support - Most programs
dedicate considerable resources to direct practice support by
helping them reorganize workflow and systems and by providing
tools to enhance practice capacity to assure continuous access and
care coordination.
• Health IT to Identify and Monitor At-Risk Patients - In addition to
requiring that practices use EHRs, some programs require the
practices to use an EHR system that feeds information to the
program sponsor as a term of participation.
• Quality Improvement Activities - All of the programs emphasize
quality improvement, supported by the use of the EHR and data
capabilities described above.
Source: Organizing Care for Complex Patients in the Patient-Centered
Medical Home (http://annfammed.org/content/10/1/60.full.pdf+html)
26
What kind of system do
you want?
• New York – Medicaid Choice
– MLTC – Medicaid Services
– Medicaid Advantage – Coordinating
Medicare and Medicaid services.
– PACE – Program for All Inclusive Care for
the Elderly.
• Florida
– All traditional long term care services
(including nursing home and community
based care)
27
Insurance Companies Offering Long
Term Care Managed Care (in Florida)
•
•
•
•
•
•
•
American Elder Care
Ameri-group
Coventry
Humana
Molina
Sunshine
United
28
And the counties?
C o u n ty E x p e n d itu re s P e r C a p ita b y F u n c tio n
N u rs in g
$ 5 9 8 .9 9
Coos
$ 3 4 3 .4 5
S u lliva n
$ 2 4 5 .7 6
C a rro ll
$ 1 8 5 .2 9
C o u n ty
C h e s h ire
$ 2 0 3 .4 3
M e rrim a c k
$ 1 8 3 .9 1
B e lk n a p
$ 1 6 5 .6 0
S tra ffo rd
$ 1 5 1 .2 3
G ra fto n
R o c k in g h a m
H u m a n S e rvic e s
$ 9 7 .9 2
H ills b o ro u g h $ 6 5 .5 1
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
A n n u a l E xp e n d itu re p e r C a p ita (2 0 1 1 -2 0 1 3 a ve ra g e )
29
Nursing home expenditures are an
increasing burden on the counties.
C u m u la tiv e S u rp lu s (D e fic it) o f N u rs in g H o m e R e v e n u e
in C o m p a ris o n to E xp e n d itu re s , 1 9 9 6 -2 0 0 4
$20
C u m u la tiv e S u rp lu s (D e fic it) in $ m illio n s
$ 0 .9
$0
$ (0 .4 )
$ (1 .9 )
$ (4 .7 )
$ (1 1 .1 )
-$ 2 0
$ (2 4 .0 )
-$ 4 0
$ (4 1 .3 )
-$ 6 0
$ (6 8 .9 )
-$ 8 0
$ (9 2 .1 )
-$ 1 0 0
1996
1997
1998
1999
2000
2001
2002
2003
2004
30
Critical Questions
•
•
•
•
•
•
•
•
•
What impact do other supports and services (and budgetary changes) have
on a successful managed care product?
How will demand for different services change as a result of aging and new
disease burden (e.g. dementia)?
Is the system of supports for aging sufficient to meet this growing demand
(caretakers, institutions)?
Is a state solution the right answer? How do regional differences impact the
questions being asked?
Does the growth of Medicare enrollment and changes in Medicaid
(expansions to 55-64-year-old adults) provide opportunities?
What does a long-term-care accountable care organization look like?
How do national policy changes (Affordable Care Act) and potential
recommendations out of the long term care commission impact New
Hampshire?
What role will the counties play in providing the services needed across the
spectrum of long-term-care supports and services (Meals on Wheels to
institutional care)?
Long-term-care expenditures are projected to grow more quickly then
revenues. How will the state and counties finance these changes?
31
New Hampshire Center
for Public Policy Studies
Board of Directors
William H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Daniel Wolf
Martin L. Gross, Chair
Emeritus
Directors Emeritus
Sheila T. Francoeur
Stuart V. Smith, Jr.
Want to learn more?
• Online: nhpolicy.org
• Facebook: facebook.com/nhpolicy
• Twitter: @nhpublicpolicy
• Our blog: policyblognh.org
• (603) 226-2500
Donna Sytek
Brian F. Walsh
Kimon S. Zachos
“…to raise new ideas and improve policy debates through quality
information and analysis on issues shaping New Hampshire’s future.”
32