Informational Forum on Integrated Managed LongTerm Care

1
Informational Forum onIntegrated
ManagedLong-Term Care

• December 11, 2008
• Charles Milligan, JD, MPH

2
Overview

• Portrait of Dual Eligibles
• Portrait of Long-Term Care
• Approaches to Managed Long-Term Care
• New Mexicos Approach and Background
• Michigans Background

3
Portrait of Dual Eligibles
4
Overall, Medicare beneficiaries are generally
healthy . . .
5
. . . but dual eligibles have lower incomes and
more health care conditions than other Medicare
beneficiaries . . .
6
and more functional impairments than other
Medicare beneficiaries.
7
On average, dual eligibles cost twice as much as
other Medicare beneficiaries.
8
Dual eligibles represent 14 of Medicaids
enrollment, yet (pre Part D) accounted for 40 of
all Medicaid spending.
Source Medicare Chartbook 2005, Kaiser Family
Foundation
9
Most of Medicaids spending on dual eligibles
historically has been for long-term care services
. . .
10
. . . due to the lack of an extensive Medicare
nursing facility (NF) benefit, compared to other
Medicare benefits.
11
A portrait of full-benefit dual eligibles in
Maryland, CY 2006 . . .

• By age, at the beginning of the year
• 0-49 23.3
• 50-64 14.4
• 65-74 22.0
• 75-84 24.3
• 85 16.1

Source http//www.hilltopinstitute.org/publicati
ons/dualsFramework.pdf
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. . . portrait continued . . .

• By gender
• Female 65.0
• Male 35.0
• Ever disabled? (from Medicaid and Medicare
  claims)
• Yes (overall) 45
• Yes, under 65 97.3
• Yes, 65 13.4
• No (overall) 55
• No, under 65 2.7
• No, 65 86.6

Source http//www.hilltopinstitute.org/publicati
ons/dualsFramework.pdf
13
. . . portrait continued.

• Deceased during CY?
• Yes 9.9
• No 90.1
• Join Medicare Advantage (including SNP)?
• Yes 9.8
• No 90.2

Source http//www.hilltopinstitute.org/publicati
ons/dualsFramework.pdf
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Dual Eligibles Medicare serves as a clinical
gateway to Medicaid
MedicareBenefits
MedicaidBenefits
Inpatient Hospital
InpatientHospital
65.4 of all nursing home admissions come from a
hospital.
Medicaid- Covered Outpatient Services
Physician
15
Portrait of Long-Term Care
16
Medicaid and Medicare are the major third-party
payers for long-term care, and out-of-pocket is
high.
17
Expenditures in Medicaid long-term care continue
to grow, especially for community-based services.
18
Medicaid is the largest payer for nursing home
care.
19
36 of Medicaid expenditures, or about 109
billion, goes toward long-term care . . .
20
Medicaid payments for long-term care are weighted
toward the elderly and people with disabilities.
21
Approaches to Managed Long-Term Care
22
The Problem, Part 1 Creating successful NF
transitions to the community requires early
intervention . . .
Source The National Nursing Home Survey
23
The Problem Part 2, Perceived Medicaid Cost
Shifting to Medicare

• Medicare program administrators and the Medicare
  Advantage plans often assert that Medicaid fails
  to adequately pay NFs, leading to insufficient
  staffing, leading to avoidable hospitalizations,
  paid by Medicare, due to falls, pressure ulcers,
  and pneumonia
• Medicare administrators assert that limited
  oversight by Medicaid agencies of HCBS providers
  and low payment rates for HCBS services lead to
  avoidable use of the ER and inpatient
  hospitalizations, which are paid by Medicare

24
The Problem Part 3, Perceived Medicare Cost
Shifting to Medicaid

• Medicaid program administrators often assert that
  Medicare program administrators fail to manage
  hospital discharges, and fail to manage Medicare
  providers, leading to avoidable expenses in
  Medicaid due to long NF lengths of stay, and
  unmanaged Medicaid benefits ordered by
  Medicare-paid physicians
• Medicaid administrators assert that overly strict
  Medicare utilization management inappropriately
  denies Medicare coverage for home health, DME,
  thereby leading to cost shifting to Medicaid

25
And the opportunity A coordinated program could
improve care and outcomes

• Coordinate (Medicare) hospital discharge planning
  with (Medicaid) community-based supports and
  services to avoid unnecessary languishing in
  nursing facilities
• Monitor quality of care in nursing facilities to
  prevent falls, pressure ulcers, and other causes
  of avoidable hospitalizations
• Coordinate Medicare home health, physician, and
  Rx services with Medicaid attendant care,
  transportation, and HCBS waiver services for a
  well-designed community-based plan of care

26
The Medicare Modernization Act of 2003 (MMA)
created Medicare Part D and Special Needs Plans
(SNPs)

• SNPs are Medicare Advantage health plans that can
  focus on a subset of the Medicare population.
• SNPs include
• Dual Eligible
• Institutional
• Chronic Condition

27
Enrollment in Medicare Advantage has grown,
although primarily in Private Fee-for-Service.
28
Medicare Advantage payments exceed traditional
Medicare, and may get reduced by Congress.
29
The Medicare Improvements for Patients and
Providers Act of 2008 (MIPPA) imposed new duties
on SNPs.

• SNPs are supposed to be special
• Dual eligible SNPs now are required to obtain
  contracts with state Medicaid agencies when they
  expand service area or enter a state
• Broad potential elements of contract
• All SNPs now must describe their care
  coordination approaches
• SNP authority will sunset on December 31, 2010
  further reauthorization will depend on being
  special

30
CMS has been increasingly supportive of
Medicare/Medicaid integration.

• August 7, 2008
• Dear State Medicaid Director
• The Centers for Medicare Medicaid Services
  (CMS) is releasing the new Integrated Medicare
  and Medicaid State Plan Preprint for States that
  want to integrate and coordinate Medicare and
  Medicaid services for dual eligible
  beneficiaries.
• CMS hopes this Preprint will help facilitate
  States efforts to move toward developing
  integrated delivery system of care for dual
  eligibles. The goal of providing the full array
  of Medicare and Medicaid benefits through a
  single health plan is to improve the quality of
  care for dual eligible beneficiaries with better
  care coordination and fewer administrative
  burdens.
• The CMS contact for the State Plan Preprint for
  Integrated Care Programs is Ms. Gale Arden,
  Director, Disabled and Elderly Health Program
  Group, who may be reached at 410-786-6810.
• Sincerely,
• Herb B. Kuhn
• Deputy Administrator

31
Despite growth in SNPs, only about 12 percent of
dual eligibles are in a dual eligible SNP . . .
Special Needs Plans Number of Plans and
Enrollment United States, 2004 to September 2008
Includes all types of SNPs Source Centers for
Medicare and Medicaid Services
32
One form of connection is a capitated managed
long-term care system in Medicaid.
States with voluntary programs MN, MA, NY, WI,
WA, FL vehicles 1915(a)(c) 1915(a)
States with mandatory programs TX, AZ,
NM vehicles 1915(b)(c) 1115
33
Yet voluntary and mandatory programs have major
differences.

• Notable advantages to a voluntary program
• Clean coordination with Medicare
• Simpler CMS approval process
• Fewer political barriers
• Notable advantages to a mandatory program
• Scale
• Elimination of selection bias/easier rate setting
• May drive take-up of Medicare Advantage SNPs, and
  resulting opportunity for coordination and quality

34
Another form of coordination is a contractual
arrangement now encouraged by MIPPA.
Coordination Agreement
SNP
State
Medicaid Benefits

• Possible elements of agreement
• Share electronic health records
• Alerts on major health events
• Crossover claim payment
• Coordinate grievance systems
• Coordination of benefits/TPL
• Share marketing info

Medicare Benefits
Dual Eligible
35
In all reported evaluations, managed LTC programs
have shown positive outcomes . . .

• Minnesotas MSHO program resulted in fewer
  hospital admissions and days, prevention of
  avoidable hospitalizations, and fewer ER visits
• Wisconsins Family Care program resulted in
  shorter hospital lengths of stay
• Texas Star Plus program resulted in shorter
  hospital lengths of stay, fewer ER visits, and
  lowered overall costs
• Arizonas program resulted in expanded access to
  HCBS

Source AARP Issue Brief No. 79 Medicaid
Managed Long-Term Care
36
. . . and satisfaction has been high . . .

• Consumer satisfaction levels, based on consumer
  and family surveys, have been high for most
  Medicaid managed long-term care programs.
  Arizona, Minnesota, and New York programs all
  report high overall levels of satisfaction.

Source AARP Issue Brief No. 79 Medicaid
Managed Long-Term Care
37
. . . but the financial breakeven point for
Medicaid often is delayed.

• For dual eligibles, the early savings often
  accrue to Medicare, in avoided hospital costs
• Medicaid costs are immediate, through managed
  care plan costs
• Medicaid savings come later, through NF-to-HCBS
  rebalancing

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New Mexicos Approachand Background
39
New Mexicos goals in its Coordination of
Long-Term Services (COLTS) program

• Promote community-based services by diverting
  potential NF admissions and shortening NF lengths
  of stay
• Promote flexible benefit design to achieve new
  models for community-based services
• Improve quality through coordination of Medicare
  and Medicaid
• Achieve financial savings by aligning Medicare
  and Medicaid incentives

40
New Mexicos Model

• Mandatory program (in Medicaid) using a
  1915(b)(c) combination waiver
• Populations
• All people who meet nursing facility level of
  care
• All dual eligibles
• Contracted Medicaid managed care organizations
  must also be statewide SNPs

41
New Mexico incorporated concepts of
self-direction.

• A separate program was designed at the same time
  Mi Via, which is a Cash Counseling HCBS
  waiver
• Individuals who qualify and receive a slot may
  opt out of COLTS into Mi Via
• Within COLTS, the managed care organizations must
  honor self-direction of personal care services

42
COLTS covered services (and service carve-outs)

• Covered Services
• Long-Term Care
• Nursing facility
• Waiver services
• Home Health Care
• Personal Care
• Acute Care Services
• Inpatient hospital
• Outpatient hospital
• Pharmacy
• Physician
• Transportation
• Dental

• Excluded Services
• Behavioral health
• Indian Health Services and Tribal 638 services to
  Native American Members (special discussion)

43
Prior to COLTS, New Mexico already emphasized
community-based care . . .
Medicaid Member Months (MMs) in Institutional
Care and Community-Based Care in New Mexico, for
People Meeting Nursing Facility Level of Care,
SFY 2006
44
. . . and dollars.
Source Burwell and Eiken, Distribution of
Medicaid Long-Term Care Dollars, FFY 2007
45
Yet New Mexico expects COLTS to promote further
rebalancing . . .
NF Transition Goals for COLTS in Year 1 (SFY 2009)
46
. . . projected to result in nearly 75 of all
member months in the community for people meeting
NF level of care
Projected Medicaid Member Months (MMs) in
Institutional Care and Community-Based Care in
New Mexico, SFY 2009
47
Michigans Background
48
Compared to the national average, Michigan has
more capacity in assisted living, and less in
personal care

• Michigan US
• Assisted living and residential care beds/1,000
  65 38 26
• Nursing facility beds/1,000 65 38 47
• Nursing facility residents/1,000 65 33 40
• Nursing facility occupancy rate 88 85
• Personal care and home care aides/1,000 65
  9 15
• Home health aides/1,000 65 21 18

Source AARP, Across the States 2006 Profiles
of Long-Term Care and Independent Living
49
In Michigan, Medicaid covers 64 of all NF
residents, and Medicare and Medicaid combine to
cover 81
Distribution of Certified Nursing Facility
Residents by Primary Payer Source, 2007

Source Kaiser Family Foundation,
statehealthfacts.org, 2007 data
50
Michigan is above average in HCBS participants
per 1,000 population . . .
Michigan Medicaid HCBS Participants, by Program,
2004
Source pascenter.org/state_based_stats/medicaid_h
cbs.php?titleMedicaid20HCBS20Datastatemichiga
n
51
. . . and below average in expenditures per
person.
Michigan Medicaid HCBS Expenditures, by Program,
2004
Source pascenter.org/state_based_stats/medicaid_h
cbs.php?titleMedicaid20HCBS20Datastatemichiga
n
52
Michigan has fewer dual eligibles than the
national average, and a much lower take-up of
SNPs.

• Michigan US
• of Medicare beneficiaries who are duals 16 19
• of Medicaid beneficiaries who are duals 13 14
• Average annual Medicaid spending per dual
  10,230 14,114
• Dual eligible enrollment in SNPs (as of 11/08)
  2,266 905,701

Sources statehealthfacts.org, 2003 data and
www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/
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Dual eligible enrollment in SNPs in Michigan

• SNP Enrollment
• Molina 1,645
• Midwest Health Plan 288
• Great Lakes Health Plan 268
• Community Choice (CareSource) 65
• Total 2,266

Source www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/
As of November 2008
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Opportunities in Michigan

• High institutional bias means
• Larger per capita dollars available in capitation
• Significant room for improvement
• Infrastructure of assisted living and home health
  exceeds national averages
• Experience with managed care

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Challenges in Michigan

• Low penetration by Medicare Advantage SNPs
• Lower than average capacity for personal care
• Timing SNPs may be reluctant to jump in while
• The federal sunset exists
• Potential Medicare Advantage rate cuts are under
  consideration

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Contact Information
Charles Milligan Executive Director The Hilltop
Institute University of Maryland, Baltimore
County (UMBC) 410.455.6274 cmilligan_at_hilltop.umbc.
edu www.hilltopinstitute.org