Opportunities for Reform: The Long- Term Care Industry Perspective James E. Introne President and CEO Catholic Health Care System New York, NY

2 Key Barriers to Reform No common understanding of what constitutes long term care; Inability of policy makers to separate long term care reform from Medicaid reform; Perception of a long term care “industry.”

3 What is Long Term Care? Long Term Care can mean many different things, but any chronic disabling condition that requires nursing home or constant supervision can bring on the need for long term care services. Long Term Care is the personal care and other related services provided on an extended basis to people who need help with activities of daily living or who need supervision due to a severe cognitive impairment. Long Term Care, sometimes referred to as elder care, includes a wide range of services that are provided over an extended period of time to people who need help to perform normal activities of daily living because of cognitive impairment or loss of muscular strength or control. Long Term Care is a variety of services which help meet both the medical and non-medical needs of people with chronic illness or disability who cannot care for themselves for long periods of time.

4 Wrong Problem = Wrong Answers By defining the “problem” in terms of long term care, we address the symptoms rather than the causes:  Stiffer fines and penalties  More surveillance, investigations and audits  Changing the culture  Rebalancing  Person-centered care  Millionaires on Medicaid

5 Medicaid as the Principle Funding Source “All or nothing” nature of Medicaid discourages informal caregiving and the efficient use of resources; Eligibility determination process discourages and delays needed services; Lack of integration of Medicaid and Medicare distorts provider decision-making and public policy determinations; Cost of Medicaid administration and fraud and abuse waste scarce resources.

6 Distribution of Elderly Living in the Community at High Risk for Nursing Home Use by Asset Level, 2003* *Source: Kaiser Commission on Medicaid and the Uninsured: The Distribution of Assets in the Elderly Population Living in the Community. June 2005.

7 Perception of a LTC Industry A diverse provider array includes participants with little in common; It is impossible for the “industry” to develop standard operating practices; The differing interests of providers inhibit an effective dialogue on matters of policy; The “industry” perception marginalizes the advocacy status of nonprofit religious and voluntary providers; No effective group of advocates for the frail elderly.

8 Opportunities for Reform Create a vision Refocus on people in need Expanded integration and care management

9 Vision: Implications of the model *Adapted from C. Evashwick and J. Riedel Managing Long Term Care. Foundation of the American College of Healthcare Executives. Mechanisms of Integration Inter-Entity Planning and Management Care CoordinationIntegrated Information Systems Integrated Financing Skilled nursing Personal care Rehabilitation Services Transportation Nutrition Spiritual care Adult day care Palliative care Hospice

10 People Who Need Long-Term Care Services, 2000* *Source: Kaiser Commission on Medicaid Facts, July 2006

11 Refocus on People in Need Elderly with physical and cognitive impairments Developmentally disabled adults Children with disabilities Non-elderly adults with disabilities

12 Expanded Integration and Care Management PACE Medicare Special Needs Plans State Medicaid Initiatives

13 PACE Programs Around the Nation as of April 2007 Source: National PACE Association. PACE and Pre-PACE Programs. National PACE Association reports 38 PACE providers and 8 Pre-PACE providers nationwide as of April 2007.

14 Number of Special Needs Plans* Dual Eligible Institutional3885 Chronic1374 *Source: Centers for Medicare and Medicaid Services. Special Needs Plan – Fact Sheet and Data Summary.

15 Nursing Home Ownership in 2003 Source: CMS, OSCAR data as of April 2003; N=16,446 facilities.

16 Home Health Care Ownership in 2000* *Based on distribution of current home health care patients in Source: U.S. Department of Health and Human Services, National Center for Health Statistics, National Home and Health Care Survey, 2000.

17 HCBS State Option Provisions in the Deficit Reduction Act As of January 1, 2007: States have option of providing package of home and community based services without waiver; Provide services to people with income up to 150% of poverty level; No budget neutrality requirement; Option to serve persons who do not require institutional level of care; Enrollment caps permitted; not required to provide statewide.

18 Managed Long-Term Care Programs StateProgram NamePopulation Covered FLFrail Elder Option (1987)Aged and disabled; NF-level LTC needs AZArizona Long Term Care System (ALTCS) (1989) Aged and disabled; NF-level LTC needs WIWisconsin Partnership Program (1995)Medically needy elderly or physically disabled adults MNSenior Health Options (MSHO) (1997)All ages TXTexas Access Reform (STAR) Plus (1998)All ages and disabled WIFamily Care (2000)Aged and disabled; NF-level LTC needs MNMnDHO (2001)All physically disabled Source: Kitchener, M., Willmott, M., Wong, A., and Harrington, C. (2006). Medicaid Managed Long-Term Care: An Introduction. UCSF National Center for Personal Assistance Services.

19 Recent Managed Long-Term Care Programs StateProgram NamePopulation Covered MAMass Health Senior Care Options (SCO) (2004) All ages FLIntegrated Long-Term Care (2005) Ages 60+ VTChoices for Care (2005)Medically needy elderly or physically disabled adults Source: Kitchener, M., Willmott, M., Wong, A., and Harrington, C. (2006). Medicaid Managed Long-Term Care: An Introduction. UCSF National Center for Personal Assistance Services.