rebalancing long-term care: new mexico’s “colts” program
DESCRIPTION
Rebalancing Long-Term Care: New Mexico’s “CoLTS” Program. May 28, 2009 Charles Milligan. Overview. Background New Mexico’s goals and approach in CoLTS Rhode Island’s background. - 2 -. Background. - PowerPoint PPT PresentationTRANSCRIPT
The Hilltop Institute was formerly the Center for Health Program Development and Management.
Rebalancing Long-Term Care:New Mexico’s “CoLTS” Program
May 28, 2009
Charles Milligan
-2--2-
Overview
Background
New Mexico’s goals and approach in CoLTS
Rhode Island’s background
-3-
Background
-4-
Dual eligibles consume a lot of Medicaid and Medicare services, and the distribution varies by service . . .
Maryland full-benefit duals, Medicare & Medcaid Expenditures (excluding crossover payments), by Service, PMPM
$607
$106$20 $22
$409
$33$58
$937
$673
$16 $72 $19$0
$200
$400
$600
$800
$1,000
Hospital Nursing Facility* Home Health Hospice Physician/Outpatient
DME
PM
PM
Medicare Medicaid
Source: The Hilltop Institute, 2008
Notes: Includes only continuously enrolled full-benefit duals with no group health coverage; Nursing Facility figures also include ICF-MR expenditures, and “Home Health” includes all Medicaid HCBS waivers
-5-
In Maryland, between 1999-2008, 74 percent of all “discrete” nursing home admissions began as Medicare stays . . .
A DISCRETE STAY includes all days of carefrom admission to discharge in a single facility
Hilltop Refined MDS data for Maryland, 1999-2008
Avg. Length of Stay
All : 648,774 100% 89 Days
Medicare (SNF) Only : 408,876 63% 20 DaysNon-Medicare (NF) Only : 166,829 26% 166 DaysInitial Medicare, to Other : 73,069 11% 299 Days
Stays
-6-
. . . and 84 percent of all “extended” stays include a Medicare span, usually at the beginning. . .
An EXTENDED STAY consists of all contiguous discrete staysacross facilities (with no more than a 30 day gap)
Hilltop Refined MDS data for Maryland, 1999-2008
Avg. Length of Stay
All : 384,156 100% 110 Days
Medicare (SNF) Only : 269,272 70% 24 DaysNon-Medicare (NF) Only : 60,379 16% 182 DaysMedicare and Other : 54,505 14% 455 Days
Stays
-7-
. . . and the initial payer for most “extended stays” was Medicare.
Private/Other11%
Medicare83%
Medicaid6%
Hilltop refined MDS data, Extended Stays in Maryland, 1999-2008
-8-
Discharging residents to the community requires early intervention . . .
0%
10%
20%
30%
40%
50%
60%
70%
80%
Community Deceased Other Institution
Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008,
limited to the stays that convert to Medicaid
Days
Reason for Discharge
-9-
. . . and by the time many residents convert to Medicaid, the odds of community reintegration are low.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
30 60 90 120 150 180 210 240 270 300 330 360 390 420 420+
Discharge to Community Transition to Medicaid
Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008,limited to the stays that convert to Medicaid
Days
-10-
New Mexico’s Goals and Approach in CoLTS
-11-
The Problem: Part 1, most NF stays that convert to Medicaid begin as a Medicare post-acute stay
83 percent of all extended stays begin with Medicare as the payer
After a 60-day length of stay, the odds of discharge to the community drop below 50 percent
After a 60-day length of stay, the percent of people who eventually convert to Medicaid first exceeds 50 percent
-12--12-
Medicare program administrators and the Medicare Advantage plans often assert that the 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, leads to avoidable use of the ER and inpatient hospitalizations, which are paid by Medicare.
The Problem: Part 2, Perceived Medicaid Cost Shifting to Medicare
-13--13-
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
The Problem: Part 3, Perceived Medicare Cost Shifting to Medicaid
-14--14-
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
-15--15-
New Mexico, like Texas and Arizona, developed a mandatory program of coordinated long-term services (“CoLTS”).
State
CMSSNP
Medicare
Medicaid
DualEligible
AllBenefits
Figure 1Capitated and Integrated Program
States with voluntaryprograms:MN, MA, NY, WI, WA, FLvehicles: 1915(a)(c); 1915(a)
States with mandatoryprograms:TX, AZ, NMvehicles: 1915(b)(c); 1115
-16--16-
New Mexico’s 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
-17-
New Mexico’s CoLTS 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
-17-
-18--18-
Covered Services Long-Term Care
• Nursing facility• Waiver services• Home Health Care• Personal Care (w/consumer
direction option)
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)
COLTS covered services (and service carve-outs)
-19--19-
Prior to COLTS, New Mexico already emphasized community-based care . . .
Number of MMs Percent
Institutional Care 36,597 27.6%
Community-Based Care 95,994 72.4%
Total 132,591 100.0%
Medicaid Member Months (MMs) in Institutional Care and Community-Based Care in New Mexico, for people meeting nursing facility level of care, SFY 2006
-20--20-
. . . yet New Mexico expects COLTS to promote further rebalancing.
Number of MMs
Percent
Institutional Care 33,711 25.4%
Community-Based Care 98,880 74.6%
Total 132,591 100.0%
Projected Medicaid Member Months (MMs) in Institutional Care and Community-Based Care New Mexico, SFY 2009
-21-
. . . and the results are not yet in. CoLTS was launched on August 1, 2008
Enrollment as of March 2009 was 26,540
Full statewide implementation occurred this month; total enrollment is approx. 38,000
Quality, access, rebalancing, and cost information to be evaluated soon.
-22-
Rhode Island’s Background
-23--23-
Compared to the US, Rhode Island has more seniors, more seniors near poverty, and fewer seniors of color
RI US
% of population 65+ (2007) 13.9 12.6
% of population 85+ (2007) 2.4 1.8
% of population 65+ of color (2007) 7.6 19.3
Median household income, 65+ (2007) $28.2k $33.2k
Source: AARP, “Across the States 2008: Profiles of Long-Term Care and Independent Living”
-24--24-
Compared to the US, Rhode Island has more nursing facility beds, filled beds, seniors in nursing homes, and fewer personal and home health aides
RI US
Nursing facility beds/1,000 65+ 60 45
Nursing facility occupancy rate 92% 85%
Nursing facility residents/1,000 65+ 56 38
Nursing facility residents/1000 75+ 104 78
Personal and home health aides/1,000 65+ 11 16
Source: AARP, “Across the States 2008: Profiles of Long-Term Care and Independent Living”
-25--25-
In Rhode Island, Medicaid covers 66% of all NF residents, Medicare only covers 9%, and 26% are private or self-pay
Source: Kaiser Family Foundation, statehealthfacts.org, 2007 data
RI%
US%
Medicaid 66% 64%
Medicare 9% 14%
Private/Other 26% 22%
Total
Distribution of Certified Nursing Facility Residents by Primary Payer Source, 2007
-26--26-
Rhode Island is below average in HCBS participants per 1,000 population, but above average in the number served in a 1915(c) waiver.
Source:http://pascenter.org/state_based_stats/medicaid_hcbs_2005.php?state=rhodeisland&project=
Number of Rhode Island Participants
Rhode Island Participants per 1,000 Population
US Participants per 1,000Population
Home Health 1,000 0.94 3.13
Personal Care Services 0 0 2.69
1915(c) HCBS Waivers 5,568 5.23 3.59
Total Medicaid HCBS 6,568 6.17 9.40
Rhode Island Medicaid HCBS Participants, by Program, 2005
-27--27-
Rhode Island has more dual eligibles than average, spends more on duals, and has a lower penetration and take-up of SNPs.
RI US
% of Medicare beneficiaries who are duals 23 21
% of Medicaid beneficiaries who are duals 20 18
Average annual Medicaid spending per dual $19,191 $14,972
Dual eligible enrollment in SNPs (as of 5/09) 3,982 923,732
* United (916)
* Blue Cross (3,066)
Number of full benefit dual eligibles 35,093 7.098 MM
Approx. percent of dual eligibles in a SNP 11.3 13.0
Sources: statehealthfacts.org, 2005 data andwww.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/
2005 data, other than SNP
-28--28-
Opportunities inRhode Island High institutional bias means
Larger per capita dollars available in capitation Significant room for improvement
Higher than average use of HCBS waivers
Higher than average % of duals
Experience with managed care
Medicaid managed care might improve take-up of SNPs.
-29--29-
Challenges inRhode Island Low penetration by Medicare Advantage
SNPs
Lower than average capacity for personal care
Lower than average Medicare $$ in nursing homes
-30--30-
Contact Information
Charles Milligan
Executive Director
The Hilltop Institute
University of Maryland, Baltimore County (UMBC)
410.455.6274
www.hilltopinstitute.org