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

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Overview

Background

New Mexico’s goals and approach in CoLTS

Rhode Island’s background

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Background

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

Maryland full-benefit duals, Medicare & Medcaid Expenditures (excluding crossover payments), by Service, PMPM

$607

$106$20 $22

$409

$33$58

$937

$673

$16 $72 $19$0

$200

$400

$600

$800

$1,000

Hospital Nursing Facility* Home Health Hospice Physician/Outpatient

DME

PM

PM

Medicare Medicaid

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

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In Maryland, between 1999-2008, 74 percent of all “discrete” nursing home admissions began as Medicare stays . . .

A DISCRETE STAY includes all days of carefrom admission to discharge in a single facility

Hilltop Refined MDS data for Maryland, 1999-2008

Avg. Length of Stay

All : 648,774 100% 89 Days

Medicare (SNF) Only : 408,876 63% 20 DaysNon-Medicare (NF) Only : 166,829 26% 166 DaysInitial Medicare, to Other : 73,069 11% 299 Days

Stays

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. . . and 84 percent of all “extended” stays include a Medicare span, usually at the beginning. . .

An EXTENDED STAY consists of all contiguous discrete staysacross facilities (with no more than a 30 day gap)

Hilltop Refined MDS data for Maryland, 1999-2008

Avg. Length of Stay

All : 384,156 100% 110 Days

Medicare (SNF) Only : 269,272 70% 24 DaysNon-Medicare (NF) Only : 60,379 16% 182 DaysMedicare and Other : 54,505 14% 455 Days

Stays

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. . . and the initial payer for most “extended stays” was Medicare.

Private/Other11%

Medicare83%

Medicaid6%

Hilltop refined MDS data, Extended Stays in Maryland, 1999-2008

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Discharging residents to the community requires early intervention . . .

0%

10%

20%

30%

40%

50%

60%

70%

80%

Community Deceased Other Institution

Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008,

limited to the stays that convert to Medicaid

Days

Reason for Discharge

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. . . and by the time many residents convert to Medicaid, the odds of community reintegration are low.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

30 60 90 120 150 180 210 240 270 300 330 360 390 420 420+

Discharge to Community Transition to Medicaid

Hilltop Refined MDS data for Maryland, Extended Stays w/Discharge 1999-2008,limited to the stays that convert to Medicaid

Days

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New Mexico’s Goals and Approach in CoLTS

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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

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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

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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

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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

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New Mexico, like Texas and Arizona, developed a mandatory program of coordinated long-term services (“CoLTS”).

State

CMSSNP

Medicare

Medicaid

DualEligible

AllBenefits

Figure 1Capitated and Integrated Program

States with voluntaryprograms:MN, MA, NY, WI, WA, FLvehicles: 1915(a)(c); 1915(a)

States with mandatoryprograms:TX, AZ, NMvehicles: 1915(b)(c); 1115

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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

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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

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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)

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Prior to COLTS, New Mexico already emphasized community-based care . . .

Number of MMs Percent

Institutional Care 36,597 27.6%

Community-Based Care 95,994 72.4%

Total 132,591 100.0%

Medicaid Member Months (MMs) in Institutional Care and Community-Based Care in New Mexico, for people meeting nursing facility level of care, SFY 2006

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

Number of MMs

Percent

Institutional Care 33,711 25.4%

Community-Based Care 98,880 74.6%

Total 132,591 100.0%

Projected Medicaid Member Months (MMs) in Institutional Care and Community-Based Care New Mexico, SFY 2009

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. . . 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.

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Rhode Island’s Background

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Compared to the US, Rhode Island has more seniors, more seniors near poverty, and fewer seniors of color

RI US

% of population 65+ (2007) 13.9 12.6

% of population 85+ (2007) 2.4 1.8

% of population 65+ of color (2007) 7.6 19.3

Median household income, 65+ (2007) $28.2k $33.2k

Source: AARP, “Across the States 2008: Profiles of Long-Term Care and Independent Living”

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Compared to the US, Rhode Island has more nursing facility beds, filled beds, seniors in nursing homes, and fewer personal and home health aides

RI US

Nursing facility beds/1,000 65+ 60 45

Nursing facility occupancy rate 92% 85%

Nursing facility residents/1,000 65+ 56 38

Nursing facility residents/1000 75+ 104 78

Personal and home health aides/1,000 65+ 11 16

Source: AARP, “Across the States 2008: Profiles of Long-Term Care and Independent Living”

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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%

Medicaid 66% 64%

Medicare 9% 14%

Private/Other 26% 22%

Total

Distribution of Certified Nursing Facility Residents by Primary Payer Source, 2007

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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 1,000Population

Home Health 1,000 0.94 3.13

Personal Care Services 0 0 2.69

1915(c) HCBS Waivers 5,568 5.23 3.59

Total Medicaid HCBS 6,568 6.17 9.40

Rhode Island Medicaid HCBS Participants, by Program, 2005

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Rhode Island has more dual eligibles than average, spends more on duals, and has a lower penetration and take-up of SNPs.

RI US

% of Medicare beneficiaries who are duals 23 21

% of Medicaid beneficiaries who are duals 20 18

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 SNP 11.3 13.0

Sources: statehealthfacts.org, 2005 data andwww.cms.hhs.gov/MCRAdvPartDEnrolData/SNP/

2005 data, other than SNP

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Opportunities inRhode 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.

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Challenges inRhode Island Low penetration by Medicare Advantage

SNPs

Lower than average capacity for personal care

Lower than average Medicare $$ in nursing homes

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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