1. 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. -3- Background

4. -4- Dual eligibles consume a lot of Medicaid and Medicare 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

5. -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 care from admission to discharge in a single facility Hilltop Refined MDS data for Maryland, 1999-2008

6. -6-... 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

7. -7-... and the initial payer for most “extended stays” was Medicare. Hilltop refined MDS data, Extended Stays in Maryland, 1999-2008

8. -8- 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 Reason for Discharge

9. -9-... 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

10. -10- New Mexico’s Goals and Approach in CoLTS

11. -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 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

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. -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 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

20. -20-... yet New Mexico expects COLTS to promote further rebalancing. 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

21. -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. -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 RIUS % of population 65+ (2007)13.912.6 % of population 85+ (2007)2.41.8 % of population 65+ of color (2007)7.619.3 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 RIUS Nursing facility beds/1,000 65+6045 Nursing facility occupancy rate92%85% Nursing facility residents/1,000 65+5638 Nursing facility residents/1000 75+10478 Personal and home health aides/1,000 65+1116 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 % Medicaid66%64% Medicare9%14% Private/Other26%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 1,000 Population Home Health1,0000.943.13 Personal Care Services002.69 1915(c) HCBS Waivers5,5685.233.59 Total Medicaid HCBS6,5686.179.40 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. RIUS % of Medicare beneficiaries who are duals2321 % of Medicaid beneficiaries who are duals2018 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 SNP11.313.0 Sources: statehealthfacts.org, 2005 data and www.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/ 2005 data, other than SNP

28. -28- Opportunities in Rhode 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 in Rhode 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 cmilligan@hilltop.umbc.edu www.hilltopinstitute.org