Health Care: Changes, Challenges & Opportunities Achieving a New Normal in Delaware

1. Health Care: Changes, Challenges & Opportunities Achieving a New Normal in Delaware Delaware Aging Network, Modern Maturity Center: March 26, 2013Rita Landgraf, Secretary, Department of Health and Social Services

2. U.S. Health Care Spending OECD = Organization for Economic Cooperation and Development * Dark part of bar = public spending * Light part = private spending 2

3. Life Expectancy By Country Source: CIA World Factbook (2012 estimates)

4. Another Impact: Aging Population ** By 2030, Delaware is projected to have the 9th-highest proportion of people age 65 and older in the U.S.

5. Fast-Growing Older Population Today, about 1 in 5 Delawareans is age 60+. By 2025, they will make up one-fourth of state’s population. And by 2030, the state’s older population is projected to have doubled from what it was in 2000 to 253,646.

6. Fast-Growing Older Population The “oldest old” population – those individuals age 85+, and most in need of critical care services – will nearly double between 2005 and 2020. Then double again by 2040.

7. Delaware’s Obesity Epidemic • Prevalence among adults has doubled from 1990 to 2010. • In 2010, 64% of adults were at an unhealthy weight. • In 2011, 37% of Delaware children were at an unhealthy weight. • Delaware’s estimated annual economic cost: $207 million

8. Trend Toward Sedentary Lives Half of Delawareans don’t get regular physical activity. 58% of children age 2-17 don’t get the recommended 1 hour a day of physical activity. 70% of children age 2-5 don’t meet that recommendation.

9. ACA: Challenge and Opportunity Delawareans benefit from health care reform by: • Increased access to health insurance and quality health care. • Being supported in community-based settings. • Promoting healthy lifestyles.

10. ACA’s Effect on Providers • Primary care re-established as gateway to medical care. • Systems and reimbursements will focus on patient outcomes and measurable standards. • Must transition from what Gov. Markell calls a “sick care system” to one that encourages healthy behavior and positive outcomes.

11. ACA’s Effect on Providers • Concern about geographic distribution of primary care providers, especially in underserved and rural areas, including Sussex. • For each member, the MCO must have a PCP available within 30 minutes or 30 miles of residence. • Every 2,000 patients = 1 PCP

12. Data on Primary Care Physicians The 2011 Primary Care Physicians in Delaware report found: • 888 active PCPs (FTE = 707 physicians; that’s down from 736 in 2008) • Population to provider ratio = 1,274 to 1 (up from 1,187 to 1 in 2008; capacity = 2,000) • 86% accept new patients, but only 69%-70% accept new Medicare & Medicaid clients

13. More Delaware PCP Data • 60% of a PCP’s time is devoted to serving Medicare & Medicaid patients, while the number of Medicaid clients alone represents 20% of the population. • Wait times for appointments for new patients: • NCCo: 11 days • Kent: 14 days • Sussex: 12 days

14. Patient-Centered Medical Homes • Transforms the organization and delivery of primary care.  • The practice treats the “whole” patient, including physical and mental health needs, coordinating care with specialists, hospitals, and home- and community-based care. • Convenient hours and secure communication organized around patient.

15. Health Benefit Marketplace • Delaware’s marketplace must go live by Jan. 1, 2014; enrolling clients by October 2013. • Approved for a state-federal marketplace partnership rather than create our own state-based marketplace. • Partnership option permits Delaware to maintain control of plan management and consumer assistance functions. • Expect to enroll up to 35,000 people.  

16. ACA: Medicaid Expansion • In January 2014, Delaware will widen eligibility up to 138% of the federal poverty level ($15,415 for an individual; $31,809 for a family of four). • State expects to cover anadditional 20,000 to 30,000 Delawareans. Federal government will pay 100% of the cost for newly eligible clients from 2014-2017; phased down to 90% of costs by 2020.

17. Delaware’s Workforce Needs • Delaware’s aging population, health care reform, and additional insured clients under Medicaid expansion and health benefit exchange will increase demands on health professionals. • To deal with shortage: Encourage nurse practitioners to practice to top of licenses, using prescriptive authority. E • Electronic medical records: As of 2012, 97% of providers enrolled in the DHIN.

18. Delaware’s Workforce Needs • Delaware experiencing shortages among mental health providers, especially in Kent and Sussex. • Use State Loan Repayment Program to attract professionals. • Telehealth will help extend resources, especially for specialty care. As of July 2012, Medicaid now reimburses for telemedicine-delivered care.

19. Delaware’s Strategies • Medicaid’s long-term care seniors transitioned to MCOs in April 2012 to better coordinate care and supports. • Governor’s budget recommends an additional $700,000 for home-delivered meals. • Gov. Markell and General Assembly invested $13 million in walking/biking trails.

20. Institutional Bias in Delaware… About 87.5% of long-term care dollars for aging and physical disabilities are spent in facilities. Community care costs Costs for institutional care • Institutional Bias in the U.S… • About 66% of long-term care dollars are spent in facilities. Costs for institutional care Community care costs Delaware ranks 38th among all states in the percentage of long-term care dollars spent on home and community-based services.

21. What the Marketplace Wants 89% That’s the percentage of people surveyed by AARP Delaware who want to age in place. They want a high quality of life that allows them to remain fully engaged in the their community.

22. Cost Avoidance/Cost Savings • Right Care, Right Time, Right Place – building access to community. • AARP estimates that for every person we support in a facility, we can support 3 in the community. • Managed LTC.

23. Integration of Primary Care, Specialty Care, Behavioral Health and Public Health Source: Institute of Medicine. Primary Care and Public Health Exploring Integration to Improve Population Health, March 28 2012.

24. Why Integrate? • Health has many contributors. • Substantial and lasting improvements will require a common goal. • Enhance the capacity of all sectors to carry out their missions. Source: Institute of Medicine. Primary Care and Public Health Exploring Integration to Improve Population Health, March 28 2012.

25. Community-Based Services • What it means: The right care in the right place at the right time. • Aging and Disability Resource Center: (800) 223-9074 or www.delawareadrc.com • Assistance for caregivers (adult day services, Alzheimer’s day treatment, respite care) and home services (attendant services, personal care, home modification, home-delivered meals) • Example: Life Center at Riverfront

26. The End We All Imagine

27. We Don’t Watch People Grow Old 1850: 70% of white aging adults lived with their children. 1950: 21% of U.S. population lived in multi-generational homes, according to Pew Research. 2012: Only 16% in U.S. lived in homes with multiple generations.

28. The Reality About 1.65 million Americans are served by hospice programs each year. That’s an increase of 136% since 2000. Still, more than 55% of Americans who die each year do not receive comfort care at the end of life. 

29. A Death-Denying Society Death, just like birth, is a part of the circle of life. It is life’s final transition. But too often our society embraces every medical option to save our loved ones, including heroic measures. Rather than deny death, we should revere it.

30. We Struggle with Goodbye “I suppose in the end, the whole of life becomes an act of letting go, but what always hurts the most is not taking a moment to say goodbye.” ~ From “Life of Pi”

31. What We Need to Do We need to have difficult discussions with our families about wishes for end-of-life care. Talk with them about hospice care, advance directives, heroic measures, organ donation. Obtain a living will, a medical power attorney and/or health care proxy.

32. Learning from Valerie Harper “Life does not owe me a shred. I don’t want to go, but it’s the reality, and I’d love people to have less fear about death and encourage them to be here now.” ~ Valerie Harper, who was diagnosed with brain cancer and is making the rounds of the media to talk about her diagnosis “Don’t have the funeral until the day of the funeral. Live today.”

33. Delaware Receives $2.48 Million CMMI Design Grant ACA created the Centers for Medicare and Medicaid Innovation (CMMI) to help transform Medicare, Medicaid and the Children’s Health Insurance Program (CHIP). Transforming Delaware’s Health: A Model for State Health Care System Innovation. Timeline for the design plan: April-October 2013 If design plan is accepted, could lead to additional funding for testing of the design. Additional funding for full implementation.

34. Opportunity: CMMI Grants Model Design Process Work Streams conducted in the following areas: payment reform; health care delivery system transformation; enhanced health data collection and analytic capacity; health policy and purchasing redesign and alignment; workforce transformation; and population-based approaches to health promotion including behavioral health. Design development will occur concurrently in each of these areas, with supporting technical assistance and expertise. Reporting and additional public input will be conducted at DHCC meetings and special public forums.

35. What is a Model? Definition of model (any initiative, strategy, tactic or policy oriented toward the Governor’s CHPDP) • DE HEAL (Healthy Eating and Active Living) • United Way of Delaware Youth Health Program • Sussex Outdoors • Sussex County Health Promotion Coalition • DE Center for Health Promotion at DSU • Healthy Weight Collaborative • DelaWELL • UD Healthy Campus • Small Employer Initiative • Delaware Small Communities Initiative

36. Data Collection • Mission, Vision, Strategy: Is your model addressing any high priority recommendations? • In what ways are you using the Governor’s Council strategically within your organization? • Program Development: What evidence-based studies are being used in program development? • Program Evaluation: Are you currently collecting data? If so, what data is being collected? • What databases are you using to collect data? • Outcome Evaluation: Do you have an evaluation plan? • What methodology was used in selecting this measurement plan? • Funding and Sustainability: Describe your greatest opportunities for growth? Describe your greatest threats? • Partnerships and Collaboration: What help do you need to better achieve your mission? • What help do you need in evaluating the effectiveness of your program? • How can the Governor’s Council help you?