1. The Hilltop Institute was formerly the Center for Health Program Development and Management. New Mexicos Coordinated Long-Term Services (CoLTS) Program February 25, 2009 Charles Milligan Medicaid Managed Care Summit

2. -2- Overview Portrait of Dual Eligibles Portrait of Long-Term Care The Problem, and New Mexicos approach in CoLTS

3. -3- Portrait of Dual Eligibles

4. -4- Dual eligibles are predominantly female, and span all age groups Female 62% Male 38% Under 65 (disabled/ ESRD) 39% 65-74 years 26% 75-84 years 23% 85+ years 13% GenderAge group Source: MedPac, June 2008; based on data from the 2005 MCBS

5. -5- Hispanic White, Non- Hispanic 57% Black, Non- Hispanic 19% 15% Other 9% Race/ethnicity Below poverty 53% 100-125% FPL 21% 125-200% FPL 19 % Over 200% FPL 6% Income status Source: MedPac, June 2008; based on data from the 2005 MCBS Dual eligibles are disproportionately white, and poor

6. -6- Overall, Medicare beneficiaries are generally healthy...

7. -7- Dual eligibles are sicker and more functionally impaired than other Medicare beneficiaries SOURCE: MedPac, June 2008; based on data from the 2005 MCBS Cost and Use file *Data from 2003 MCBS http://www.cms.hhs.gov/MCBS/Downloads/ CNP_2003_dhsec8.pdf

8. -8- Even though they have Medicaid, dual eligibles cost Medicare more than other Medicare beneficiaries... Dual 16% Non-dual 84% Dual 25% Non-dual 75% Medicare enrollees by eligibility, 2005 Medicare spending by eligibility, 2005 Source: MedPac, June 2008

9. -9-... in all major services... Source: MedPac, June 2008

10. -10-... and dual eligibles also use all services at a higher rate. Source: MedPac, June 2008

11. -11- Dual eligibles also consume a lot of Medicaid services, and the distribution varies by service... 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

12. -12-... and Medicaid also pays for Medicare cost sharing... 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

13. -13-... which completes the picture for Medicaid expenditures for dual eligibles by service. 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

14. -14- Inpatient Hospital Inpatient Hospital Inpatient Hospital Dual Eligibles: Medicare serves as a clinical gateway to Medicaid Medicaid- Covered Outpatient Services Nursing Facility Medicaid Benefits Medicare Benefits Physician

15. -15- Portrait of Long-Term Care

16. -16- Medicaid and Medicare are the major third-party payers for long- term care, and out-of-pocket is high.

17. -17- Expenditures in Medicaid long-term care continue to grow, especially for community-based services.

18. -18- Medicaid is the largest payer for nursing home care.

19. -19- 36 percent of Medicaid expenditures, or about $109 billion, goes toward long-term care...

20. -20- In Maryland, between 1999-2008, 74 percent of all discrete nursing home admissions began as Medicare stays... A DISCRETE STAY includes all days of care from admission to discharge in a single facility Hilltop Refined MDS data for Maryland, 1999-2008

21. -21-... and 84 percent of all extended stays include a Medicare span, usually at the beginning... An EXTENDED STAY consists of all contiguous discrete stays across facilities (with no more than a 30 day gap) Hilltop Refined MDS data for Maryland, 1999-2008

22. -22- For extended stays, the vast majority of initial NF admissions came from a hospital... Hilltop refined MDS data, Extended Stays in Maryland, 1999-2008

23. -23-... and the initial payer was Medicare. Hilltop refined MDS data, Extended Stays in Maryland, 1999-2008

24. -24- Discharging residents to the community requires early intervention... Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008, limited to the stays that convert to Medicaid Days

25. -25-... and by the time many residents convert to Medicaid, the odds of community reintegration are low. Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008, limited to the stays that convert to Medicaid Days

26. -26- The Problem, and New Mexicos Approach in CoLTS

27. -27- The Problem: Part 1, most NF stays that convert to Medicaid begin as a Medicare post-acute stay 91 percent of all extended stays begin as a post-hospital admission 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 drops below 50 percent After a 60-day length of stay, the percent of people who eventually convert to Medicaid first exceeds 50 percent

28. -28- 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

29. -29- 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

30. -30- 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

31. -31- New Mexico, like Texas and Arizona, developed a mandatory program of coordinated long-term services. State CMS SNP Medicare Medicaid Dual Eligible All Benefits Figure 1 Capitated and Integrated Program States with voluntary programs: MN, MA, NY, WI, WA, FL vehicles: 1915(a)(c); 1915(a) States with mandatory programs: TX, AZ, NM vehicles: 1915(b)(c); 1115

32. -32- New Mexicos 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

33. -33- New Mexicos 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 -33-

34. -34- 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)

35. -35- Prior to COLTS, New Mexico already emphasized community- based care... Number of MMsPercent Institutional Care36,59727.6% Community-Based Care95,99472.4% Total132,591100.0% Medicaid Member Months (MMs) in Institutional Care and Community-Based Care in New Mexico, for people meeting nursing facility level of care, SFY 2006

36. -36-... and dollars. Source: Burwell and Eiken, Distribution of Medicaid Long-Term Care Dollars, FFY 2007

37. -37- Yet New Mexico expects COLTS to promote further rebalancing... 1234 GroupGroup DescriptionPercent of Total MMs Transition Goal (% of MMs) Average NF MMs SFY 2006 Transitioned Individuals – Avg. NF MMs 1Full Year63.1%10%12.05.0 2New Arrivals12.4%15%6.22.5 3Discharged to Community 9.5%20%6.11.5 4Eligibility Ended6.4%n/a6.1n/a 5Short Stay3.4%n/a3.2n/a 6Short Out, Hospital3.1%n/a10.1n/a 7Short Out, Community2.1%20%5.04.0 NF Transition Goals for COLTS in Year 1 (SFY 2009)

38. -38-... projected to result in nearly 75 percent of all Member Months in the community for people meeting NF level of care Number of MMs Percent Institutional Care33,71125.4% Community-Based Care98,88074.6% Total132,591100.0% Projected Medicaid Member Months (MMs) in Institutional Care and Community-Based Care New Mexico, SFY 2009

39. -39-... and the results are not yet in. CoLTS was launched on August 1, 2008 Full statewide implementation will occur in a few months Quality, access, rebalancing, and cost information to be evaluated soon.

40. -40- Contact Information Charles Milligan Executive Director The Hilltop Institute University of Maryland, Baltimore County (UMBC) 410.455.6274 cmilligan@hilltop.umbc.edu www.hilltopinstitute.org