Two Decades of Progress in Delivering Long-Term Services and Supports in Ohio: But What’s Next?

1. Two Decades of Progress in Delivering Long-Term Services and Supports in Ohio: But What’s Next? Bob Applebaum Western Reserve Area Agency Annual Meeting

2. National Long-Term Care Numbers • 6 million older people with disability– will more than double by 2040 • Long-term care about one-third of Medicaid expenditures (Ohio 36%) • Medicaid about 22% of state budgets (Ohio 24%) • 63% of Medicaid LTC funds to nursing homes– varies by state • Two-thirds of residents now on Medicaid

6. Population 60 plus by County

7. Population 60 plus by County

10. An Aging America: Are You Aging? • Gravity more powerful than kryptonite • You are starting to look like your parents • You can’t stay awake for Sat Night Live • You have given up hope of being a professional athlete (mostly men) • You have given up hope of finding a sensitive partner (Exclusively women)

11. The Ohio LTC Context • Large state-- 7th highest population 65 and older • High supply of NF beds per pop. 75+ (ranks 6th) • High number of NF beds 93,000 (ranks 7th) • Traditionally high reimbursement rates for NF--changing • One of two states with NF formula in state statute • 42nd state to get assisted living waiver • No state level home care program • No personal care option under Medicaid • Restrictive Medicaid program (209B state) • 1.6 mill 65 plus– 85 plus grown by 75k in last 10 yrs • Last state in the nation to ban leisure suits

12. Ohio Context Continued • Large expansion of home care waiver to more than 30,000 each day • AL waiver 4100 participants in 2013 • NH reimbursement flat for last 8 years • 72 of Ohio’s 88 counties now have home care property tax levies-- $165 million in 2011 • State efforts to balance culminating in Unified Budget Workgroup-- sets financing and balancing targets • 2010 Legislature passes Diversion and Transition Initiative • 2012 Legislature passes Integrated Care Demonstration and includes AAA care management involvement

13. Proportion of Ohio's Population with Physical/Cognitive Disability Receiving Care in Different Settings, 2011

14. NF Admissions by Payment Sources (1992-2011) • 1992 1997 2001 2007 2009 2011 • Total Admissions (in thousands) • 71 130150 201 197 216 • Medicare Admissions (in thousands) • 30 8091 127 109 149 • Medicaid Admissions (in thousands) • 18 19 24 25 27 29

15. Proportion of Total & Medicaid Nursing Home Residents Still Living in a Facility

16. Nursing Facility Capacity and Occupancy, Over Time

17. Nursing Home Resident Characteristics • Age 59 and under Today 12.7% 1994 4% • Age 65 and under 19.1% 7% • Medicaid 59 and under 16.7% • Medicaid 65 and under 24.2% • Today’s nursing home-- Higher proportion of men, minorities, married

18. Characteristics of Medicaid LTCSS Consumers, 2012

19. Average Number of People Age 60 and Older Receiving LTCSS, Paid by Medicaid, 1997-2011

20. Use of Nursing Facilities Compared to Home and Community-Based Services by People with Physical and/or Cognitive Disability, Paid by Medicaid

21. Number of People Age 60 and Older Residing in Nursing Facilities or Enrolled in a Waiver Per 1,000 Persons in Population

22. Total Medicaid Expenditures on LTCSS for People Age 60 and Older : 1997 - 2011 at 2011 PMPM Rates (in Thousands of Dollars)

23. Changes But Future Challenges • Decreased over 60 use of nursing homes by 11% in last 15 years • Increased under 60 use by 26% • Decreased overall use, but decreased private pay share of nursing home funding • Very small proportion of U.S. population with Long-term care insurance- Insurers getting out of business

24. Acute and long-term care systems don’t live in the same world– provider fragmentation Medicare and Medicaid as funders don’t work together and in fact cost shifting has been the norm The lack of integration is bad for consumers --- bad for quality, bad for costs Overall system unsustainable One problem Addressed– New One Gets Added to the List

25. Who Are the Medicaid Consumers in Ohio and How Much of the Resources each Group Use? Aged Blind & Disabled 22% Families, Women & Children 78% 30% 70% Source: Health Policy Institute of Ohio. Ohio Medicaid basics 2009

26. DOM working on efforts to implement ICDS demonstration – MY CareOhio OMA and CMS have agreed to a demonstration with evaluation to start on May of 2014 All Medicaid/Medicare NF residents must enroll in ICDS Many unanswered questions both about the final intervention and outcomes Integrated Care Demonstration

27. Region Plan Northwest Aetna, Buckeye Southwest Aetna, Molina West Central Buckeye, Molina Central Aetna, Molina East Central CareSource, United Northeast Central CareSource, United Northeast Buckeye, CareSource United MyCare Ohio Regions

28. LTCSS as Proportion of Total Medicaid Per-Member, Per-Month Exp. For Ohio’s Population Using LTCSS by Age Group, 2010

29. State to bring all Medicaid long-term services recipients into Managed Care and hope is that dual eligible individuals will leave Medicare fee for service for combined managed care Evidence on dual integration – cost savings, quality? Could it have unintended side effect of expanding Medicaid participation? Will this approach negatively impact the strong aging network in the state? How impact NF rates? Integration of LTCSS and Health Care System Issues

30. Today Ohio has 305,000 individuals of all ages with severe disability and 122,000 (40%) receive LTC services through Medicaid Today 24% of state budget is Medicaid– 36% goes to LTC By 2020, 348,000 with severe disability and 138,000 projected to receive Medicaid LTC services By 2020, 30-35% of state budget could be Medicaid, with 40-45% going to LTC By 2040, 600,000 with severe disability and 237,000 projected to receive Medicaid LTC services By 2040 more than 50% of state budget could be Medicaid with more than 60% going to LTC Ohio’s Challenges:

31. System Unsustainable: Now What? • Supports for family and other caregivers to assist older person to stay in community • Support for communities to become more aging friendly • Too many nursing home beds as a nation—varies dramatically– Industry transformation to right size • Integration of Medicaid and Medicare– does not really address these issues

32. System Unsustainable: Now What? • Serious prevention – lower prevalence of disability– Good news is disability rates dropping slightly for older people– Bad news increasing for under 60 population • Use of technology to promote more independence, even when disability occurs (low tech to high tech) • Support for individuals with moderate level of disability and moderate income- Now pretty good system for very poor, very disabled. • 8% of 65 plus on Medicaid in community, 66% on Medicaid in nursing homes

33. Policy and the Future • Even with changes the current system is simply not sustainable • Short-term window where “boomer growth” remains small, before the major increase • The current system was never designed– • Meaningful change is very slow • We often have policy changes with unplanned consequences. Hospital reform --new nursing home • LTC system must be innovative and efficient-- • Heavy pressure driven by Medicaid budget concerns–

34. Bob Applebaum Applebra@Miamioh.edu Scrippsaging.org (Scripps web site) Contact info