Impact of the Money Follows the Person Program July 25, 2019 - - PowerPoint PPT Presentation

Impact of the Money Follows the Person Program

July 25, 2019

Community Living Policy Center

• Aims to advance policies and practices that promote

community living outcomes for individuals with disabilities of all ages through research and knowledge translation.

• The CLPC received support from the National Institute for

Disability, Independent Living, and Rehabilitation Research (NIDILRR) within the Administration for Community Living, U.S. Department of Health and Human Services (Grant # 90RTCP0004). The contents of this webinar do not necessarily represent the policy of NIDILRR, ACL, or HHS, and you should not assume endorsement by the Federal Government.

Community Living Policy Center Partners

• Lurie Institute for Disability Policy at Brandeis University
• University of California, San Francisco (UCSF)
• Association of University Centers on Disabilities (AUCD)
• Autistic Self Advocacy Network (ASAN)
• Disability Rights Education & Defense Fund (DREDF)
• Disability Policy Consortium (DPC)
• Centene Corporation
• National Association of States United for Aging and Disabilities (NASUAD)
• Mike Oxford, Topeka Independent Living Resource Center
• Henry Claypool, National Policy Expert
• Disability and Aging Collaborative

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Presenters

Carol Irvin Mathematica Steve Kaye University of California San Francisco Nicole Jorwic The Arc of the United States

The Cost Savings and Quality of Life Implications of the Money Follows the Person Demonstration

July 25, 2019

Carol V. Irvin

• Prin

incip ipal A l Aim ims

• Reduce reliance on institutional care
• Develop community-based long-term care
• pportunities
• Enable people with disabilities to participate fully

in their communities and improve their quality of life

Money Follows the Person (MFP) Rebalancing Demonstration

7

Legislative History

• Established

ed b by Deficit R Reduction A Act o

• f 2

2005

• 5-year demonstration and $2 billion in grant funding for states
• Exten

tended ed and e expanded ed b by the A e Affordable e Care A e Act o

• f 2

2010

• 5-year extension and additional $2 billion in grant funds
• Exten

tended ed by the M e Medicaid E Exten tender ers A Act o

• f 2

2019

• Added $112 million for federal fiscal year 2019

8

OR AZ NM WY UT

RI

CT

AK HI SC GA AL NC TN

MA

ME

NH VT

NY

NJ

PA

DE

MD

WV KY OH MI MT ID WA TX CA NV CO ND SD NE IA MS IN IL MN WI MO AR OK KS LA VA FL

State with MFP program No MFP program in state

A Popular Demonstration...

9

Source: Mathematica analysis of Medicaid Analytic eXtract (MAX) data from 2006 through 2014.

1,221,024 1,147,364 1,084,786

• 200,000

400,000 600,000 800,000 1,000,000 1,200,000 1,400,000 2006 2007 2008 2009 2010 2011 2012 2013 2014

Number of Individuals

More Than One Million Eligible for MFP In Any Given Year

Older adults Physical disabilities Intellectual disabilities Total

...Sizeable Eligible Population...

10

Source: Mathematica analysis of MFP enrollment records submitted by states to CMS.

1, 1,473 473 5, 5,67 673 11,924 924 19, 19,728 728 30, 30,141 141 40, 40,693 693 51, 51,676 676 63, 63,337 337

10 20 30 40 50 60 70

De Dec 20 2008 08 De Dec 20 2009 09 De Dec 20 2010 10 De Dec 20 2011 11 De Dec 20 2012 12 De Dec 20 2013 13 De Dec 20 2014 14 De Dec 20 2015 15 Thousands

Total cumulative number of MFP transitions grew steadily from 2008 through 2015

...But Not a Large Demonstration

11

• Average per-beneficiary-per-month (PBPM)

expenditures declined by $1,840 (23 percent)

Older adults

• Average PBPM expenditures declined by

$1,730 (23 percent)

People with physical disabilities

• Average PBPM expenditures declined by

$4,013 (30 percent)

People with intellectual/developmental disabilities

Community-Based Services Are Less Costly than Institutional Care

12

Savings Were Accrued by Medicaid

• MFP p

participants ts ge gener erated to total s savings gs o

• f $

$978 m million in me medic ical a al and L LTSS c cos

• sts
• $1 billion in savings to Medicaid
• $25 million increase to Medicare because of gains in Medicare coverage

during the first year

13

Assessing Costs Extremely Difficult— Could Not Assess All Costs

• Housing

g – room

• om a

and b boar ard

• Costs b

beyond the f e first y t year a aft fter t the t transiti tion

• Attempted to look at costs two years post transition, but results were inconclusive

14

Changes in Costs Not Unique to MFP

• The d

e dec ecline i in costs o

• bserved a

among M MFP p parti ticipants i is similar to wh what w t we s e see ee for

• thers wh

who t transiti tion o

• uts

tside t the d e dem emonstration

• Did MFP transition b

benefi ficiaries es w who w would not h have t e transitioned ed o

• ther

erwi wise? e?

• Never detected a robust increase in transitions after MFP began
• MFP participants had characteristics that suggested they had fewer connections to the

community

15

Other Avenues for Cost Savings

• Did MFP hel

elp b ben eneficiaries r rem emain l longer i in the c e community ty?

• Did MFP reduce the likelihood of someone returning to facility level care?
• When someone returns to a facility, is the stay shorter because of MFP?
• Did M

MFP p provide m e more e access to to medical c care? e?

• If MFP provides higher quality HCBS, are medical care costs lower as a result?

16

Supported infrastructure changes

• Helped states establish formal transition programs
• Catalyst to interagency collaboration between

health and housing

• Improved access to community-based LTSS

Stronger State LTSS Systems

MFP Provided Other Benefits

17

Source: Mathematica’s analysis of MFP QoL surveys and program participation data submitted to CMS through May 2016. Note: The analyses are based on surveys from 13,795 MFP participants. All post-transition results were statistically different from pre-transition results at the .01 level, two-tailed test.

aA declining percentage indicates improvement in depressive symptoms, or fewer unmet needs, or fewer barriers to community integration. bMeasured as “Any unmet need for personal assistance services” in bathing, eating, medication management, and toileting. cMeasured as affirmative responses to the question: “Is there anything you want to do outside [the facility/your home] that you cannot do now?”

66.2 46.0 79.6 18.3 76.8 61.9 51.8 83.1 38.7 91.3 7.6 91.8 92.4 34.0 83.5 36.6 91.0 6.3 92.4 91.4 29.8 20 40 60 80 100 Overall life satisfaction Depressive symptoms (a) Satisfaction with care Any unmet need for personal care (a,b) Respect and dignity Satisfaction with living arrangements Barriers to community integration (a,c)

Percentage

Pre-transition One year post-transition Two years post-transition

Invaluable Quality of Life Improvements

18

Source: Mathematica’s analysis of MFP QoL surveys and program participation data submitted to CMS through May 2016. Note: The analyses are based on surveys from 13,795 MFP participants.

18.3 10.8 1.6 2.7 8.0 7.6 4.1 1.4 1.5 2.6

0.0 2.0 4.0 6.0 8.0 10.0 12.0 14.0 16.0 18.0 20.0

Any unmet care need Bathing Meals Medications Toileting

Percentage

Pre-transition One Year Post-transtion

Unmet Needs Declined Post Transition

19

20 13.5 22.5 52.5 61.0

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Had Depressive Symptoms Did Not Have Depressive Symptoms

Percentage

Autonomous in 6 Areas

Pre-Transition Post-Transition

52.4 77.4 89.2 96.5

Had Depressive Symptoms Did Not Have Depressive Symptoms

Can Get Needed Sleep

Pre-Transition Post-Transition

Unmet Needs Declined Post Transition

Source: Mathematica’s analysis of MFP QoL surveys and program participation data submitted to CMS through May 2016. Note: The analyses are based on surveys from 6,688 MFP participants. Depressive symptoms are defined by affirmative responses to either of two questions: During the past week have you felt sad or blue? And During the past week have you felt irritable?. The autonomy measure is the percentage who answered “Yes” to all the following: (1) Can you go to bed when you want?, (2) Can you be by yourself when you want to?, (3) When you are at home, can you eat when you want to?, (4) Can you choose the foods that you eat?, (5) Can you talk on the telephone without someone listening in?, and (6) Can you watch TV when you want to?. The quality of sleep question was Can you get the sleep you need without noises or other disturbances where you live?

Next Steps?

• Dem

emonstr trati tions a are te e temporary

• Either end or adopted permanently
• Commu

mmunity-based b ben eneficiaries a are l les ess costl tly a and h have a a high gher q quality ty o

• f l

f life t e than those r e residing i g in facilities es

• Divert beneficiaries from facility-based care
• Focus on the transition when a facility admission occurs

21

Early Access to Community Services Leads to Less Reliance

• n Institutional

Care

Transition

• Increase the likelihood of

returning to the community and community-based services when an institutional stay occurs

Divert

• Decrease the likelihood of a

long institutional stay

Make Community-Based LTSS Available As Early As Possible

22

For More Information

23

MFP we webpage ge

https://www.medicaid.gov/medicaid/ltss/money-follows-the-person/index.html

Carol I Irvin, Mathem emati tica

CIrvin@mathematica-mpr.com

Steve Kaye CLPC Webinar 7/25/19

Evidence for the Impact of Money Follows the Person

• State programs
• 2007: 30 states + DC
• 2011–12: 14 more states
• 6 states never participated
• 1 (OR) dropped out
• Cumulative total 9/07–6/18:

91,540 transitions

• I/DD: 14,856
• Non-I/DD: 76,684
• Some states transition >2%
• f institutional pop per year

Source: Mathematica, CMS

Money Follows the Person transitions

Data sources

• MFP Transitions: Mathematica Policy Research reports & CMS
• Institutional utilization
• Nursing home residents & occupancy: Federal CASPER & OSCAR databases, from

UCSF & Kaiser Family Foundation reports, with adjustments

• Nursing home residents: CMS tabulations from Minimum Data Set (MDS)
• ICF/IID population: Residential Information Systems Project (RISP) reports from
• U. Minnesota, updated by RISP team
• LTSS expenditures
• Truven/IBM Watson Health reports w/ adjustments
• CMS Medicaid Budget & Expenditure System (MBES) for bulk “supplemental

payments”

Analysis, Part I: Non-I/DD population

• States classified as High, Medium, or Low/Non-MFP States
• Based on 2012-17 ave. annual number of MFP transitions, relative to the state

population

• High MFP: CT, DE, DC, GA, HI, ID, KS, LA, MD, MA, NE, ND, OH, RI, TN, VT, WA
• Low/Non-MFP states:
• No MFP program: AK, AZ, FL, NM, UT, WY + OR (early dropout)
• Few non-I/DD transitions: AL, CA, CO, IA, KY, MN, NC, OK, SC, VA
• Institutional population: NH residents without ID (~98%)
• LTSS expenditures: Non-I/DD-specific HCBS + nursing homes
• Home health not counted as HCBS
• “Supplemental payments” excluded from NH expenditures

• Change 2007-17
• High

–7.1%

• Medium

–4.5%

• Low

–1.7%

Source: CASPER/OSCAR tabulations from KFF & UCSF

Nursing home population declined in High & Medium MFP states

• Change 2007-17

(# per 100,000 pop, averaged across states)

• High

–71.0

• Medium

–44.7

• Low

–40.2

Source: CASPER/OSCAR tabulations from KFF & UCSF

Proportion of state pop in nursing homes: High MFP states had largest decline

• Change 2012–18
• High

–7.0%

• Medium

–3.7%

• Low

–2.4%

• “Permanent-stay”

based on residents’ expectations when admitted/readmitted

Source: MDS 3.0

Permanent-stay nursing home residents: Reductions in High/Medium MFP states

• Change 2007-17

(percentage points, averaged across states)

• High

–6.1

• Medium

–5.4

• Low

–4.0

Source: CASPER/OSCAR tabulations from KFF & UCSF

Nursing home occupancy: Greater reduction in High & Medium MFP states

• Change 2010–16

($ per capita, adjusted for inflation)

• High

–$29.52

• Medium

–$23.79

• Low

–$10.77

• CA & NM omitted due to

missing/ inconsistent data

Source: Truven/IBM Watson Health & CMS MBES reports

Medicaid nursing home expenditures declined more in High & Medium MFP states

• Change 2010-16

(percentage points, averaged across states)

• High

+7.6

• Medium

+7.3

• Low

+4.0

• CA, FL, ID, NJ, NM omitted

due to missing/ inconsistent data

Source: Truven/IBM Watson Health reports

Rebalancing: High & Medium MFP States had larger increase in HCBS % of LTSS Spending

Analysis, Part II: I/DD population

• States classified as High, Medium, or Low/Non-MFP States
• Based on 2012-17 ave. annual number of MFP transitions of people with I/DD,

relative to the state population

• High-MFP: AR, CT, ID, IL, IA, KS, LA, MS, MO, NJ, ND, OH, OK, SD, TX, VA, WA
• Low/Non-MFP states:
• No MFP program: AK, AZ, FL, NM, UT, WY + OR (early dropout)
• No I/DD transitions: AL, ME, MI, RI, SC, VT, WV
• Few I/DD transitions: HI, MN, NH
• Institutional population: ICF/IID pop + NH residents with ID (~2%)
• LTSS expenditures: I/DD-specific HCBS & ICF/IID
• “Supplemental payments” excluded from ICF/IID expenditures

• Change 2008-17

(# per 100,000 pop, averaged across states)

• High

–16.6

• Medium

–12.0

• Low

–4.5

Source: RISP; CASPER/OSCAR tabulations from KFF & UCSF

Larger declines in institutionalized state pop in High & Medium MFP states

• Change 2010–16

($ per capita, adjusted for inflation)

• High

–$18.25

• Medium

–$20.63

• Low

–$3.53

• NC omitted due to missing

data

Source: Truven/IBM Watson Health & CMS MBES reports

Medicaid ICF/IID expenditures declined in High & Medium MFP states

• Change 2010-16

(percentage points, averaged across states)

• High

+9.4

• Medium

+8.8

• Low

+1.8

• NC omitted due to

missing data

Rebalancing: High & Medium MFP States had larger increase in HCBS % of LTSS Spending

Source: Truven/IBM Watson Health & CMS MBES reports

Conclusions

• States with robust MFP programs substantially reduced nursing home

& ICF/IID utilization relative to other states

• Reduced nursing home occupancy rates suggest that transitioned

residents are not being replaced by new residents

• Reductions in “permanent-stay” NH residents are particularly

important

• Suggests that MFP targets those would not otherwise return to community
• High & Medium MFP states rebalanced their Medicaid LTSS systems

faster than Low/non-MFP states

• MFP appears to have been successful in helping states shift away

from institutional services and toward HCBS

• Tiny program that works: Permanent part of Medicaid?

Money Follows the Person- EMPOWER Care Act (S. 548, H.R. 1342)

Nicole Jorwic, J.D. Senior Director of Public Policy, The Arc of the United States

Money Follows the Person

Money Follows the Person (MFP) gives states additional federal Medicaid funds to help transition people from institutions to the community Congressional Intent: Rebalance the Long-Term Care system from institution to community Mechanism: Enhanced federal match earned on HCBS for each MFP participant enrolled in HCBS program following discharge from a qualified institution

Federal Demonstration Project

• Originated under the Deficit Reduction Act of 2005
• Expanded by the Affordable Care Act Rebalancing Initiative

Congressional Intent: Rebalance the Long-Term Care system from institution to community **Strong Bi-Partisan support Mechanism: Enhanced federal match earned on HCBS for each MFP participant enrolled in HCBS program following discharge from a qualified institution

History

Legislative History of MFP

• First became law through the The Deficit Reduction Act of 2005

(S. 1932)

• Reauthorized as part of the Affordable Care Act (H.R. 3590)

(Senate passed the House version) and the

• Program expired September 30, 2016

Recent MFP Activity

There have been several short term extension bills, but the EMPOWER Care Act (S. 548, H.R. 1342) would extend and improve the MFP program through 2023 A 4.5 year extension passed the House in June now we will look to the Senate

The EMPOWER Care Act improves MFP by reducing how long someone must be in a nursing home before becoming eligible to transition from 90 days to 60. The bill also enhances the reporting and accountability of MFP funding Requires the federal government to identify and share the most effective state strategies for transitioning beneficiaries from institutional to qualified community settings, including how such strategies vary for different types of beneficiaries.

Changes in Current Legislation

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