Suppo pporting ng Choice i in a an Increa easing ngly C - - PowerPoint PPT Presentation

Suppo pporting ng Choice i in a an Increa easing ngly C Complex W World: d: What at a a Great at T Time f for Sel elf-Direc ection! n!

Sha haron L Lewis is May 2018 2018

B A C K G R O U N D

DATA AND CONTEXT

3

HEALTHCARE AND THE U.S. ECONOMY

Source: IOM, http://www.nationalacademies.org/hmd/~/media/Files/Activity%20Files/Quality/LearningHealthCare/Release%20Slides.pdf

For the majority of the past 40 years, health care costs have increased annually at a greater rate than the economy as a whole. Health care costs constitute over 17%

• f U.S. GDP; when

we include human services, the total is 35%. A 30% increase in personal income

• ver the past

decade was effectively eliminated by a 76% increase in health care costs.

4

WE ARE SPENDING MORE ON HEALTHCARE AS A PERCENTAGE OF GDP

2 4 6 8 10 12 14 16 18

United States Netherlands Germany France Denmark Canada Australia United Kingdom

Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor

5

WE HAVE LOWER LIFE EXPECTANCY

Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor

70 72 74 76 78 80 82 84 86 88

United States Netherlands Germany France Denmark Canada Australia United Kingdom Life Expectancy - females at birth (2013) Life Expectancy - Males at birth (2013)

6

WHEN SOCIAL SERVICES SPENDING IS INCLUDED, WE’RE IN THE MIDDLE

5 10 15 20 25 30 35 40 45 50

United States Netherlands Germany France Denmark Canada Australia United Kingdom Health Spending as share (%) of GDP (2013) Public Social Spending as share (%) of GDP (2013)

Source: stats.oecd.org with thanks to Elizabeth H. Bradley and Lauren A. Taylor

7

FEDERAL LTSS POLICY

1935 US enacts Social Security Act/Old Age Assistance

• program. Ban
• n funding to

public institutions. Gives rise to private nursing facilities. 1965 Medicare and Medicaid added to the SSA; institutional bias (nursing facilities) memorialized in statute. 1965 Older Americans Act enacted. 1974 Social services added to SSA, including homemaker services, transportation, adult day care, employment training nutrition assistance. 1980 Mental Health Systems Act provides funding for community mental health programs with an emphasis on deinstitutionalization. 1981 1915(c) establishes HCBS waivers 1982 Katie Beckett/TEFRA state plan

• ption for HCBS

1990 Pepper Commission makes recommendations

• n LTSS financing.

1990 Americans with Disabilities Act (ADA) becomes law. 1993 Clinton Health Care Plan includes plans to expand HCBS; plan is never enacted.

1995 HHS & RWJF initiate the Medicaid cash and counseling demonstration.

1999 Olmstead Supreme Court decision promotes right to community integration under the ADA 2001 New Freedom Initiative established to remove barriers to community living for people with disabilities. 2005 Deficit Reduction Act: expands HCBS funding; MFP created; HCBS state plan

• ption; self-

direction of personal care.

1935 1965 1974 1980 1981 1990 1993 1999 2001 2005 2013 2001

2010 Affordable Care Act expands access to HCBS through BIP, CFC, CLASS. 2013 CLASS Act repealed,; bipartisan LTC Commission established. LTC Commission unable to agree on recommendations.

LTSS: A HUGE PART OF OUR MEDICAID SYSTEM

8

+ 5.2 million persons received Medicaid LTSS in CY 2013, based

• n CMS estimates. Data is

imperfect. + 1.5 million (28%) of people who received LTSS from Medicaid received institutional services. + 42% of full benefit dual eligible individuals use Medicaid LTSS; 87% of their Medicaid expenditure are LTSS

MEDICAID LTSS Over 5 million people depend on Medicaid-funded LTSS

1.5 3.5 0.2

• 0.5

1.0 1.5 2.0 2.5 3.0 3.5 4.0

Institutions HCBS Both

People who received Medicaid-covered LTSS, CY 2013, n = 5.2 million, (Data from CMS) LTSS = $158.2 billion across institutional and HCBS settings

Many individuals who receive Medicaid-funded LTSS are also dual eligible individuals, who are covered under both Medicare and Medicaid.

MEDICAID: THE PRIMARY PAYER

9

FEW OPTIONS Who pays for LTSS in the US?

Medicaid 52% Other Public 21% Out of pocket 19% Private Insurance 8% + Employer-sponsored and commercial healthplans rarely offer LTSS benefits + 86% decline in private LTC policies since 2000 – fewer than + Private LTC insurance benefits relatively limited and short-term

10

PEOPLE WITH DISABILITIES ARE DISPROPORTIONATELY EXPENSIVE

Source: http://www.kff.org/medicaid/state-indicator/distribution-of-medicaid-enrollees-by-enrollment-group/; http://www.kff.org/medicaid/state-indicator/medicaid-spending-by-enrollment-group/

43% 19% 34% 19% 9% 21% 14% 40%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Enrollment Spending People with Disabilities Aged Adult Children

WHY MEDICAID?

11

+ The national median annual cost

• f care for home health care is

$49,188. Cost of home care services is…

• Nearly 3x higher than the

income of a 2 person household living at FPL.

• 1.2x higher than the median

household income for a 65+ household.

Source data: HMA using cost data from Genworth, 2017. Note: does not include IDD or BH-related LTSS system costs.

COSTS LTSS is unaffordable for most individuals and families.

$18,200 $49,188 $85,775 $16,240 $40,000

$- $20,000 $40,000 $60,000 $80,000 $100,000 HCBS (Adult day), 2017 HCBS (Homemaker), 2017 Institutional (Semi-Private Room), 2017 FPL Household (2 people), 2016 Median Household Income 65+, 2017

HCBS & Institutional Care Compared to Income

HCBS (Home Health Aide) 2017

AGING POPULATION

12

+ Big age shift in the composition of the 65+ population between 2010-2050. + The elderly grow older: those over age increasing from 6% to 11.2%

• f the US population from 2010 –

2050. + By 2050, over 4% of U.S. population will be over age 85

Source: CBO, Rising Demand for LTSS for Elderly People, (June 2013).

DEMOGRAPHICS Future costs driven by aging of the over 65 population.

AGE WAVE: “Oldest” States in 2030

13

+ Map shows the % of each state’s population that will be 65+ in 2030. + What is the US average? + 20% of the US population will be 65+ in 2030. + What is the range for the US? + 13.2% (UT) – 27.1% (FL) + Top 5 “oldest” states by 2030: + MN, NM, WY, ME, and FL. + Key issues to note: + Oldest states will face the greatest imbalance between workforce and potential demand for LTSS.

Source: HMA, based on US Census Bureau.

AGE WAVE: Highest Rate of Growth in 65+

14

+ Map shows the annual population growth rate for individuals 65+ between 2015-2030. + What is the US rate of growth? + US population will grow by 3.5% from 2015-2030. + What is the range for the US? + <2% (DC and WV) – 6.7% (AZ) + Top 5 states, highest growth rates 2015-2030: + TX, AK, NV, FL, and AZ. + Key issues to note: + Lowest rates of growth across the Great Lakes and Norther/Southern Mid- West.

Source: HMA, based on US Census Bureau.

15

INSTITUTIONAL CARE

Heavy reliance on institutions by older adults in 2015.

13% 18% 46% 28%

86% 77% 48% 67% 1% 4% 6% 4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Under 21 (1.2 m. or 22%) Adults, 21-64 (1.9 m. or 37%) Seniors 65+(2.1 m. or 41%) All (5.2 m.)

People who use Medicaid LTSS by Population Group Source data: CMS, April 2017.

Institutional Only HCBS Only Institutional and HCBS

1 in 5 adults <65 use institutional LTSS 1 in 2 adults 65+ use institutional LTSS

16

SELF-DIRECTED SERVICES

Participation in Self-Directed Services continues to grow.

200,000 400,000 600,000 800,000 1,000,000 1,200,000 50 100 150 200 250 300 2011 2013 2016

Number of participants Number of programs

Programs Statewide Participants

Source: AARP PPI Report, April 2018 + Number of participants grew 40% between 2011-2016 + MLTSS states – 80% growth; non-MLTSS states 110% growth + About 27 out of every 1000 Americans with disabilities participate in self-directed services

SELF-DIRECTION

17

SELF-DIRECTED SERVICES

Participation in Self-Directed Services continues to grow.

200,000 400,000 600,000 800,000 1,000,000 1,200,000 50 100 150 200 250 300 2011 2013 2016

Number of participants Number of programs

Programs Statewide Participants

Source: AARP PPI Report, April 2018 + Number of participants grew 40% between 2011-2016 + MLTSS states – 80% growth; non-MLTSS states 110% growth + About 27 out of every 1000 Americans with disabilities participate in self-directed services

SELF-DIRECTION

18

STATE MANAGED LTSS STATUS, MARCH 2018

Source: HMA, March 2018.

MLTSS has had little impact on self-direction enrollment.

Active MLTSS Program as of 2016 Intends to Implement MLTSS by 2018 Active capitated Duals Demo (MLTSS for duals in demo) States to Watch for Potential MLTSS Activity

Note: Though ID is largely a FFS Medicaid state, it offers a Medicare Medicaid Coordinated Plan for duals that includes MLTSS

DC

19

HEALTH DISPARITIES: PEOPLE WITH DISABILITIES, 2015

20

WHAT IMPACTS HEALTH OUTCOMES?

10% Health Care

5% Environmental Exposure 30% Genetic Predisposition 15% Social Circumstances

40% Behavioral Patterns

Source: Schroeder, Steven A. We Can Do Better – Improving the Health of the American

• People. N Engl J Med

2007;357:1221-8

STATES

W H A T I S I M P O R T A N T T O

HEALTHCARE REFORM 2018 AND BEYOND

22

Insurance reform vs delivery system Personal Responsibility (work requirements) Consumer-directed healthcare (high deductible plans) MCOs, ACOs, provider-led entities, alternate payment models Volume vs Value: Outcome-focused Data and technology (both admin and individual) Medicaid still under threat

STATE LTSS OBJECTIVES

23

Accountability Budget predictability; cost efficiencies Innovation and flexibility Improved Outcomes; Quality Better Health; Integration of Care; Rebalancing Administrative simplification/capacity

24

STATE SPENDING ON HCBS VS INSTITUTIONAL CARE (APD)

High degree of difference across states.

Development of limited support waivers and targeted options (MD, PA); expansion of self- direction. Intervene earlier to divert, reduce Medicaid demand: Medicaid Section 1115 waivers that provide targeted in- home supports to people not otherwise eligible for

• Medicaid. (MN)

2017 bill introduced to establish LTSS for all qualified state residents funded through a payroll tax. (WA)

EFFORTS TO ACCELERATE REBALANCING/HCBS

25

Local county levy programs- dedicated senior services for those not yet Medicaid eligible (divert, delay need for institutional care). (OH) Alzheimer’s Disease Supportive Services Program; evidence- based chronic condition self management (ACL) Medicare Advantage CY2019 Final Call Letter to expand definition of Health Related Supplemental Benefits. (CMS)

PLANS/PROVIDERS

W H A T I S I M P O R T A N T T O

PROVIDERS AND HEALTHPLANS

27

Consumers driving value, behavioral economics Simplification & Ease

• f Use

Consumer experience Accessibility Alignment of consumer incentives Integration of care/SDOH “We have to stop funneling people through our highly professionalized view of the health care system and start breaking it down and make it much, much simpler,” Andy Slavitt, 2017.

28

EMERGING INNOVATIONS IN MLTSS - VBP

Payment approach Metrics

Greater Value, Higher Quality

+ Must link payments to

• utcomes in an intentional

manner. + New CMS Innovation Acceleration Program: Incentivizing Quality and

• utcomes in Community

Based LTSS Programs

Key Points

WHAT IS VALUE?

29

V

(Value) = Q x S (Service Volume) (Quality)

$

(Cost)

30

VALUE-BASED PAYMENTS

In most cases, “value-based” payment means provider risk through capitation, bundled payments or substantial gain/loss-sharing systems These payment presuppose advanced PLEs, i.e., organized groups of providers that have achieved clinical and financial integration and are equipped to accept risk

WHEN CMS OR STATES CREATE REQUIREMENTS FOR “VALUE- BASED” PAYMENT, THEY ARE INDIRECTLY SETTING IN MOTION THE DEVELOPMENT OF PROVIDER LED ENTITIES (PLES) AND POTENTIAL CONSOLIDATIONS.

31

VBP MAY BE A CHANCE TO GET PAID BY THE MEDICAL SYSTEM FOR DIRECT SUPPORT OUTCOMES AND TO MOVE TOWARDS MORE CARE INTEGRATION

✚ Helping people engage in community ✚ Helping people get and keep jobs ✚ Helping people get into and stay in school ✚ Helping people get and stay housed ✚ Helping people stay out of jails ✚ Helping people stay healthy ✚ Helping people stay out of the hospital ✚ Helping people build meaningful relationships

VALUE-BASED PAYMENTS

PEOPLE

W H A T I S I M P O R T A N T T O

HEALTH C CARE AC ACCESS

SOCIAL DETERMINANTS OF HEALTH

33

CO COMMUNIT ITY CON CONTEXT EDUCATI TION ON NEIGHBOR ORHOOD OOD A AND E ENVIRON ONMENT FINANCI NCIAL STABIL ILIT ITY

$

34

Social Determinants and LTSS go hand in hand. Bottom Line: Potential to use LTSS expertise to help MCOs work on housing, employment, education and other efforts.

Disability advocates for years have argued that safe and stable housing + jobs = better health MCOs, providers are increasingly responsible for broad health

• utcomes.

State MLTSS contracts including other social determinants

• AZ and NJ require specialists in housing, employment and

education (AZ only) on MCO staff

• TN focused on employment outcomes
• MN and FL ask about SDOH in RFPs
• IA put SDOH screening in health risk screening
• PA requires “innovation project” in housing from MCOs

SOCIAL DETERMINANTS OF HEALTH

35

WORKFORCE CAPACITY

Future workforce needs outpace capacity.

+ Current workforce – nearly half are women ages of 45-64; 28% born outside of the United States. + BLS projects demand for home care workers will grow by 633,000 by 2024; and, the projections reflect recent trends but DO NOT explicitly factor in projected population growth, gaining of the 65+ population. + Labor force participation among women ages 20-64 will increase by only 1.2 million in total by 2024; as compared to 7.3 million in the previous decade.

Source: US Home Care Workers: Key Facts, PHI, 2017.

Workforce Demand Workforce Supply

Huge Gap

36

DIRECT SUPPORT WORKFORCE COMPENSATION

Two-thirds (68%) work part time or for part of the year, and 23 percent live below the federal poverty line (compared to 7% of all U.S. workers). 52% of home care workers and 39% of nursing assistants rely on some form

• f public assistance.

About 9 in 10 home care workers and nursing assistants are women, more than half (58% and 54%, respectively) are people of color, and over one quarter (28%) are immigrants.

Source: US Home Care Workers: Key Facts, PHI, 2017.

Average Home Care Wage in 2017: $10.49/hour

37

Expand direct care workforce capacity for

• lder adults: Develop

workforce strategies (AZ, CT, MA, TN, WA, WI) and target wage increases in 11 states. Promote consumer-directed personal attendant care: Allow individuals to identify paid caregivers from among family, friends, others. Expand telehealth, including remote monitoring; employ community paramedicine to extend access (NV). Support family caregivers (HI, WA, RI, NJ, NY, DC, CA, GA, IL, TN and others; 16 states participating in NASDDDS’ Supporting Families CoP).

EXPANDING AND SUPPORTING DIRECT CARE WORKFORCE

SELF-DIRECTION

M O V I N G F O R W A R D

39

SELF-DIRECTED SERVICES

Building reciprocal relationships Community membership; citizenship Working, volunteering Transportation Living in home

• f choice with

people you love Health and safety needs

Quality of Life

40

SELF-DIRECTED SERVICES IN THE NEW HEALTHCARE WORLD

• Demonstrating

effectiveness and efficiency

• Technology
• Consumer

preference and demand

• Consumer

incentives

• Supported-

decisionmaking

• Solutions for states,

payers, plans OPPORTUNITIES

• Funding
• Workforce
• Technology/

infrastructure

• Lack of payer

diversity

• Assessment:

algorithm vs human subjectivity

• Program integrity

CHALLENGES

• Can SDS be part of

VBP models?

• Role of case

management/ supports coordinator/ consultant

• Ability to

demonstrate quality

• Role of FMS in new

SDOH models? QUESTIONS

QUESTIONS? SHARON LEWIS Principal

202-617-1536 slewis@healthmanagement.com www.healthmanagement.com