Reining in Long Term Care Costs While Providing Good Care: Mission Impossible

1
Reining in Long Term Care Costs While Providing
Good Care Mission Impossible?

• The National Conference of State Legislatures
• 6th Health Policy Conference
• Virginia Dize, Associate Director for HCBS
• National Association of State Units on Aging
  (NASUA)

2
Recent significant events are pushing states to
serve people with long term care needs in the
community.

• The Olmstead Decision
• The Presidents New Freedom Initiative
• Systems Change Grants

3
In attempting to make changes in their long term
care structures, states are facing these
challenges

• Workforce shortages
• Budget shortfalls
• Quality concerns
• Competing interests children, adults with
  disabilities and older persons

4
The demand for more home and community based
services is increasing

• Over the next 25 years, the number of older
  adults with 2 or limitations in the activities of
  daily living will increase by one-third.
• The aging of the baby boom generation will
  increase the demand for long term care services
  provided their way.
• More than half of older adults receive assistance
  from unpaid caregivers about 3/4 of adults aged
  18-64 rely exclusively on unpaid care.

5
State responses to the current and future
challenges in long term care

• Increased emphasis on home and community based
  services
• Consumer direction
• A renewed focus on quality
• Coordination/integration of information and
  access
• Integration of multiple programs and funding
  streams

6
Consumer Direction

• Consumer-directed programs and services
• Offer people maximum choice and control over
  their services.
• Is not a one-size-fits-all concept but is
  designed to respond to the level of choice and
  control each individual wants.

7
Consumer Direction

• Consumer-directed programs and services
• Give consumers the option of selecting, managing
  and dismissing their workers.
• Permit consumers to hire family members and
  friends as service providers.
• May include giving consumers cash or vouchers

8
Consumer Direction

• In 1998, NASUA surveyed 21 consumer-directed
  home and community based service programs in 13
  states
• Colorado, Illinois, Kansas, Maine, Michigan, New
  York, North Dakota, Oklahoma, Oregon,
  Pennsylvania, Vermont, Washington and Wisconsin.
  

9
Consumer Direction

• Most of the consumer-directed (CD) programs
  studied by NASUA
• Targeted adults with physical disabilities of all
  ages with significant ADL limitations
• Offered a wide range of services
• Used assessment, care planning and case managers

10
Consumer Direction

• States in the NASUA study offered consumer
  direction because they believed these programs
• Promote consumer choice
• Are more cost-effective than agency-provided
  services
• Respond to a lack of agency-based providers

11
Consumer Direction

• The CD programs studied by NASUA
• Permit consumers to select their own worker
• Give consumers limited responsibility for
  payments and rely on fiscal agents to do the
  paperwork
• Rely primarily on Medicaid funding

12
Consumer Direction

• The CD programs studied by NASUA
• Generally use less restrictive functional
  eligibility than nursing home level of care
• Some (16 of 21 programs) serve individuals with
  cognitive impairments
• Set requirements for training, background checks,
  and qualifications of workers

13
The Cash and Counseling Demonstration

• Funded by The Robert Wood Johnson Foundation and
  DHHS/ASPE
• Operated under 1115 waivers
• 3 states Arkansas, Florida and New Jersey
• Cashing out Medicaid personal care benefit (AR
  and New Jersey) or Waiver services (FL)

14
The Cash and Counseling Demonstration

• Fiscal intermediary organizations handle payment
  functions for most consumers
• Uses an experimental design in which consumers
  are randomized to the cash or traditional
  service group

15
Consumer Direction

• Arkansas Independent Choices data indicate
  that
• Medicaid beneficiaries in the cash option were
  more likely to receive personal assistance (9
  vs 40)
• Institutional services for the traditional group
  were 18 higher
• Medicaid costs for both groups were virtually
  identical

16
Consumer Direction

• The outside evaluation of the Arkansas project
  reported these findings
• 93 would recommend the (cash and counseling)
  program to others
• 82 say the program has improved their lives (65
  say a great deal)

17
Consumer Direction

• Better outcomes were reported for the Arkansas
  cash and counseling group in the following areas
• Access to paid care
• Increased satisfaction and reduced
  dissatisfaction with service quality
• Reductions in unmet needs
• Enhanced quality of life

18
Consumer Direction

• Results from Arkansas also indicate
• Consumers are managing their cash budgets
  responsibly without major instances of fraud and
  abuse

19
Consumer Direction

• NASUAs Independent Choices Project (1997-2000)
• Funded by The Robert Wood Johnson Foundation
• Developed a Consumer Direction Tool to aid state
  self-assessments
• 8 states developed CD reform agendas AR, ME,
  MD, MA, NH. ND, PA and RI

20
Consumer Direction

• Under a joint NASUA and NCOA project, Promoting
  Consumer Direction in Aging Services, 5 states
  each year will develop consumer direction
  agendas. Current states
• Nevada, North Carolina, South Carolina,
  Washington and West Virginia

21
Consumer Direction What does the future hold?

• Consumer-directed programs are increasing - 188
  programs were identified in a survey conducted by
  NCOA in 1999-2000
• RWJ and HHS are conducting an environmental
  assessment to identify states that want to try
  cash and counseling (without randomization)
• CMS Independence Plus Initiative

22
Consumer Direction What does the future hold?

• Consumer direction has entered the mainstream.
  Based on what we know so far, this models
  advantages include
• Greater responsiveness to consumers preferences
  and needs
• Higher consumer satisfaction
• No major instances of fraud or abuse
• Cost neutrality