Overview of Recent LongTerm Care Initiatives

1
Overview of Recent Long-Term Care Initiatives

• Presentation to
• Governors Health Reform Commission
• Long-Term Care Workgroup

Catherine W. Harrison Senior Health Policy Analyst
November 20, 2006 Richmond, VA
2
Presentation Outline

• Overview of the Joint Commission on Health Care
• Recent Long-Term Care Issues

3
Background

• The Joint Commission on Health Care (JCHC)
  was created by the 1992 Session of the General
  Assembly to continue the work of the Commission
  on Health Care for all Virginians, established in
  1990.
• The purpose of the Joint Commission on
  Health Care is to study, report, and make
  recommendations on all areas of health care
  provision, regulation, insurance, liability,
  licensing, and delivery of services. JCHC seeks
  to ensure that the greatest number of Virginians
  receives quality, cost-effective health care and
  long-term care services.

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Mission of the JCHC

• JCHC focuses on five main policy areas
• health insurance and access to care for the
  uninsured,
• health care cost and quality,
• health workforce issues,
• behavioral health care (as of July 1, 2003), and
• long-term care.
• Two subcommittees evaluate specific health care
  topics
• Long-Term Care and Medicaid Reform Subcommittee.
• Behavioral Health Care Subcommittee.

5
Membership of the JCHC

• Ten members of the House of Delegates, appointed
  by the Speaker of the House.
• Eight members of the Virginia Senate, appointed
  by the Senate Rules Committee.
• The Secretary of Health and Human Resources is an
  ex officio member.

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Current JCHC Members

• Del. Philip A. Hamilton, Chair
• Sen. Stephen H. Martin, Vice-Chair
• Del. Clifford L. Athey, Jr. Del. Robert H.
  Brink
• Del. Benjamin L. Cline Del. Franklin P. Hall
• Del. Kenneth R. Melvin Del. Harvey B. Morgan
• Del. David A. Nutter Del. John M. OBannon,
  III
• Del. John J. Welch, III
• Sen. J. Brandon Bell, II Sen. Harry B.
  Blevins
• Sen. R. Edward Houck Sen. Benjamin J. Lambert,
  III
• Sen. Linda T. Puller Sen. Nick Rerras
• Sen. William C. Wampler
• The Honorable Marilyn B. Tavenner
• Denotes members of the Long-Term Care and
  Medicaid Reform Subcommittee
• Denotes Chair of the Long-Term Care and
  Medicaid Reform Subcommittee

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Presentation Outline

• Overview of the Joint Commission on Health
  Care
• Recent Long-Term Care Issues

8
Workforce Issues

• Staff Report Access and Availability of
  Geriatricians
• HJR 135 (2004), which was tabled in House Rules,
  would have required a study of the access to and
  availability of geriatricians. The study was
  conducted at the request of Del. Morgan.
• Findings of the study include
• 14,000 geriatricians are needed nationally to
  meet the needs of the elderly population.
  Estimates suggest 36,000 geriatricians will be
  needed within 25 years.
• 7,500 are in practice nationally.
• In Virginia, the Board of Medicine lists 962
  doctors self-reporting a specialty in geriatrics.
  Only 566 list a practice address in Virginia.
• Possible barriers to entering geriatric practice
  include
• Medical problems of older people have often been
  viewed as unexciting and irreversible.
• Physician interest in geriatrics builds on
  interest in primary care (which is now
  weakening).
• Compensation for both academic and nonacademic
  primary care physicians and geriatricians remains
  relatively low compared to that of procedure
  oriented specialists.
• Providers dependence on Medicare for revenue
  once they are in practice.
• Lack of faculty role models.
• Options approved by JCHC at the November 9, 2006
  Decision Matrix meeting include
• Option II Request by letter from the Chairman
  that the Virginia Geriatric Education Center
  report to the Commission prior to the 2008
  Session on its recommendations for improving
  access to and availability of geriatricians.
• Option III Request by letter from the Chairman
  that the Health Workforce Advisory Committee in
  its deliberations consider the issues of the
  access to and availability of geriatricians in
  the context of future health workforce shortages
  associated with the aging of Virginias
  population.

9
Workforce Issues

• Staff Report Impact of Barrier Crime Laws on
  Social Service and Health Care Employers
• SJR 126 of the 2006 General Assembly Session
  directed JCHC to study the impact of barrier
  crime laws on social service and health care
  employers.
• Final report will be presented in 2007, at the
  conclusion of the two-year study.
• Barrier crime laws prohibit persons convicted of
  certain statutorily-defined crimes from obtaining
  employment with certain employers, primarily
  those employers specializing in the care of
  vulnerable populations, such as children, the
  elderly, and those with mental disabilities.

10
Long-Term Care Issues

• Critical issues identified by AARP during their
  July 11, 2006 presentation include
• Lack of public understanding of long-term care.
• Lack of consumer access to information about
  services.
• Lack of access to services.
• Lack of choice by the consumer.
• Lack of coordination of services for the client.
• Lack of evaluation data on services and providers
  to ensure quality care for the consumer.
• A diffusion among state agencies providing LTC
  services and lack of coordination.
• To address these issues AARP developed a
  multi-pronged solution including
• Establish designated leadership with a single
  point of accountability.
• Develop a comprehensive long-term care plan.
• Have a strong consumer education plan.
• Work toward a unified long-term care budget.
• As a first step, AARP proposed state agencies
  report their LTC expenditures by type of service
  and classification of client.
• JCHC approved the following options during the
  2006 Decision Matrix meeting
• Option IIa Introduce a joint resolution
  requesting that state agencies report their
  long-term care expenditures by type of service,
  classification of client, and funding stream to
  the Virginia Department for the Aging. (Due date
  of the report to be determined.)

11
Assisted Living Facility Reform

• SB 1183 (Hanger) and HB 2512 (Hamilton), as
  passed by the 2005 General Assembly and signed by
  the Governor, addressed a number of previously
  reported problems by
• Providing for the licensure of assisted living
  facility (ALF) administrators
• Allowing expedited suspensions of facility
  licensure in cases of imminent danger
• Increasing maximum civil penalties from 500 to
  10,000 per inspection cycle and
• Allowing the money collected via civil penalties
  to provide education and technical assistance to
  improve the standard of care.
• During the 2005 Session, JCHC supported a budget
  amendment to increase the Auxiliary Grant (AG)
  rate from 894 a month to 1250 a month. The
  final approved budget provided a 50 increase,
  raising the payment to 944.
• Budget amendments to cover increased Medicaid
  costs and to eliminate the local match were also
  submitted.
• During the 2006 Special Session, an amendment
  raising the AG rate to 982 a month for FY 2006
  was approved. In addition, the AG rate increased
  to 1,010 a month for FY 2007 and FY 2008.
• During the November 9, 2006 Decision Matrix
  Meeting, the following options were approved
• Option II Include an update on the JLARC report
  on the Impact of Assisted Living Regulations in
  the LTC and Medicaid Reform Subcommittee workplan
  for 2007.
• Option IV Include an update on the final DSS
  and DHP ALF regulations in the 2007 subcommittee
  workplan.
• DEFERRED UNTIL JANUARY MEETING, Option III
  Introduce a budget amendment to increase the AG
  rate.

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Medicaid Reform

• JCHC approved options from the November 9, 2006
  Decision Matrix include
• Option II Include an update on the
  Massachusetts Health Care Reform Initiative in
  the 2007 subcommittee workplan.
• Option VII Introduce a joint resolution
  encouraging DMAS to expand the use of managed
  care where feasible.
• Option VIII Introduce a joint resolution
  requesting DMAS study the potential impact of
  modifications to existing programs for public
  subsidy of employer-sponsored or other private
  health insurance coverage for Medicaid-eligible
  individuals.
• Option IX Introduce legislation granting
  authority to DMAS to pursue federal approval to
  expand buy-in programs that allow expanded
  participation in the Medicaid and FAMIS programs.
• Option X Include an update on the
  recommendations of the Medicaid Revitalization
  Committee in the 2007 subcommittee workplan.
• Option XI Include an update on the expansion of
  PACE and regional models of Medicaid/Medicare and
  Acute/LTC integration is the 2007 subcommittee
  workplan.
• Option XII Include an update on the final Blue
  Print for the Integration of Acute and Long-Term
  Care in the 2007 subcommittee workplan.
• Option XIII Include an update on the
  implementation of the LTC Partnership Program in
  Virginia on the 2007 subcommittee workplan.

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Medicaid Reform (cont.)

• A number of options have been deferred to the
  January meeting for approval, including
• Option III Introduce a budget amendment
  directing DMAS, upon federal approval, to expand
  population-based disease management programs that
  target high cost and/or high prevalence disease
  states for which nationally accepted evidence
  based guidelines exist.
• Option IV Introduce a budget amendment to
  provide access to enhanced benefit accounts, or a
  similar mechanism, in which recipients are
  rewarded for compliance with aspects of their
  care plan through financial incentives that can
  be used to purchase healthcare related goods and
  services not otherwise covered by the Medicaid
  program.
• Option VI Introduce a budget amendment to
  implement a web-based claims submission system.
• Option XIV Introduce a budget amendment to
  produce and implement a LTC Partnership
  educational campaign.

14
Pain Management Standards for LTC Facilities

• HJR 160 (Brink, 2004) would have required JCHC to
  examine the issue of developing a pain
  management standard for LTC facilities in
  Virginia. The House Rules Committee tabled HJR
  160 but requested a review of the issue by JCHC.
• A review was conducted and presented in 2004.
  JCHC continued to address the issue by including
  the topic on its 2005 workplan and assembling a
  workgroup.
• Several actions have been taken to improve pain
  management policies within the Commonwealth
  including
• Clarification of the intractable pain law that
  allows for higher doses of prescription
  medication to be provided for pain
• Development of the first guidelines in the nation
  for the use of opioids in managing pain by the
  Medical Society of Virginia (MSV)
• Endorsement of the MSV guidelines by the Board of
  Medicine, as authorized by the General Assembly
  and
• Integration of pain management into Virginias
  medical schools curricula.

15
Pain Management Standards for LTC Facilities
(cont.)

• Multiple pain management guidelines and standards
  are available.
• American Medical Directors Association.
• American Geriatric Society.
• American Medical Association.
• American Pain Society/ American Academy of Pain
  Medicine.
• Federation of State Medical Boards of the United
  States, Inc.
• Joint Commission on Accreditation of Health Care
  Organizations.
• World Health Organization.
• LTC Pain Management Workgroup identified three
  major barriers to effective pain management in
  LTC facilities, including
• Education,
• Cultural challenges, and
• Systemic problems.
• The workgroup identified several initiatives
  that are currently underway in Virginia to
  address many of the barriers recognized by the
  workgroup.
• After considering the numerous activities and
  public and private initiatives that are underway,
  the workgroup concluded that establishing pain
  management standards for LTC facilities would be
  ineffective and unnecessary.

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PACE

• The Program for All-Inclusive Care for the
  Elderly (PACE) offers an array of services to
  elderly clients and provides an alternative to
  institutionalized LTC.
• An individual must be age 55 or older and meet
  the criteria for admission to a nursing facility.
• For a capitated payment, the PACE provider
  furnishes all of an individuals needed services
  as determined by the interdisciplinary PACE team.
• Providers typically receive payments from
  Medicaid and Medicare.
• A small percentage of PACE payments may come from
  private pay individuals or long-term care
  insurance.
• During the 2005 Decision Matrix meeting, JCHC
  approved the introduction of a budget amendment
  for 2.5 million GFs for up to six potential PACE
  sites. The final budget included a one time
  appropriation of 1.5 million GFs in FY 2007 for
  start-up costs for six sites.
• At the November 9, 2006 Decision Matrix meeting,
  JCHC approved
• Option II Introduce a budget amendment for
  500,000 GFs in FY 2008 to provide start-up
  funding through DMAS for up to two potential PACE
  programs.

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Joint Commission on Health Care

• JCHC Internet website
• http//legis.state.va.us/jchc/jchchome.htm
• Includes meeting schedules, studies, reports,
  
• and legislation.
• Joint Commission on Health Care
• 900 E. Main Street, First Floor West
• P. O. Box 1322
• Richmond, VA 23218
• 804-786-5445/(FAX) 804-786-5538
• charrison_at_leg.state.va.us