Medicaid home and community based long term care trends in the u s and maryland
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Medicaid Home and Community Based Long Term Care – Trends in the U.S. and Maryland. Nancy A. Miller Department of Public Policy, UMBC nanmille@umbc.edu , 410-455-3889 Briefing, MD Senate Finance Committee January 15, 2004 Funded by:

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Medicaid home and community based long term care trends in the u s and maryland
Medicaid Home and Community Based Long Term Care – Trends in the U.S. and Maryland

Nancy A. Miller

Department of Public Policy, UMBC

nanmille@umbc.edu, 410-455-3889

Briefing, MD Senate Finance Committee

January 15, 2004

Funded by:

National Institute of Disability and Rehabilitation Research, Department of Education

Information Brokering for Long Term Care, The Robert Wood Johnson Foundation


Purpose
Purpose in the U.S. and Maryland

  • Provide overview of Medicaid home and community based care services (HCBS)

  • Compare Maryland to national trends with regard to HCBS

  • Describe strategies states can pursue to support community based long term care and summarize effectiveness


Medicaid home and community based long term care trends in the u s and maryland

Levit, et al. Health Affairs 2003 in the U.S. and Maryland


Us medicaid long term care expenditures 2002 82 billion
US Medicaid Long Term Care Expenditures, 2002 ($82 billion) in the U.S. and Maryland

Source: Burwell, 2003. CMS Form 64 Expenditure Data. Cambridge, MA: MedStat


Forces fueling hcbs growth
Forces Fueling HCBS Growth in the U.S. and Maryland

  • Consumer demand for alternatives to nursing homes especially by people with disabilities

  • 1999 Supreme Court Olmstead decision

  • Concerns with quality of nursing home care

  • Costs of institutional care


Three types of medicaid home and community based services
Three Types of Medicaid Home and Community Based Services in the U.S. and Maryland

  • Home health care –

    • Only required for those who would be in an institution

    • Mandatory state plan

    • More restrictive financial eligibility

  • Personal care state plan option

    • available in only 28 states (including MD)

    • More restrictive financial eligibility

  • HCBS waiver programs

    • Must be nursing home eligible

    • Can and do limit slots & expenditures


Medicaid home and community based service waivers
Medicaid Home and Community Based Service Waivers in the U.S. and Maryland

  • Waiver of:

    • Statewide requirements

    • Comparability of services for different population groups

    • Income and resource requirements – up to 300% SSI, as with NH eligibility

  • Wide range of services


Medicaid home health personal care and waiver participants 2001 2 117 948 participants
Medicaid Home Health, Personal Care and Waiver Participants, 2001(2,117,948 participants)

Kitchener, Ng, & Harrington, 2003, Medicaid HCBS Program Data. San Francisco, CA: UCSF


Medicaid hcbs expenditures by program 2001 total 22 billion
Medicaid HCBS Expenditures by Program, 2001: Total, $22 billion

Kitchener, Ng, & Harrington, 2003. Medicaid HCBS Program Data 92-01. San Francisco, CA: UCSF




1915c waivers
1915c Waivers Maryland

  • Since Congressional authorization in 1981, 1915c waivers for home and community based care have been an important, and growing Medicaid program

  • Six states participated in 1982; by 1997, all states provided waiver services to at least 1 of 7 target groups

  • Participants have grown from 235,580 in 1992 to 832,915 in 2001

  • Expenditures have grown from $3.8 million in 1982 to $2.16 billion in 1992 and $14.22 billion by 2001



1915c waivers md
1915c Waivers -- MD Maryland

  • Model waiver for children with disabilities – 1985 (funds expended)

  • MR/DD waiver – 1986 (funds expended)

  • Waiver for Older Adults – 2001

  • Living at Home: MD Community Choice Care (working age adults) – 2001

  • Waiver for children with autism – 2001

  • Traumatic Brain Injury waiver -- 2003

  • Subsequent waiver numbers for MD in the charts underestimate MD activity, as most national numbers are available only through 2000 or 2001


Participants by recipient type 2001 total number 832 915
Participants by Recipient Type: 2001 MarylandTotal Number: 832,915

Kitchener, Ng, and Harrington, 2003. Medicaid HCBS Program Data. SF:UCSF.


Md participants by recipient type 2002 approximately 9 795
MD Participants by Recipient Type: 2002; approximately 9,795 Maryland

Kitchener, Ng, and Harrington, 2003. Personal communication, CHPDM, 2004


Medicaid waiver expenditures by recipient group 2001 total expenditure 14 218 236 802
Medicaid Waiver Expenditures Marylandby Recipient Group, 2001Total Expenditure: $14,218,236,802

Kitchener, Ng & Harrington. 2003. Medicaid HCBS Program Data. SF: UCSF


Waiver expenditures by service category 2001 total 14 billion
Waiver Expenditures by MarylandService Category, 2001Total: $14 billion

Kitchener, Ng, & Harrington, 2003. Medicaid Home Care. SF: UCSF






State variation in medicaid per capita 1915c waiver participants for aged and disabled 2000
State Variation in Medicaid Per Capita 1915c Waiver Participants for Aged and Disabled, 2000


State variation in access to hcbs what contributes
State Variation in Access to HCBS – What Contributes? Participants for Aged and Disabled, 2000

  • Differences in demand for long term care

  • Variation in state resources to meet demand

  • State LTC system goals and effectiveness of strategies to attain those goals


Three broad strategies i increase hcbs capacity
Three Broad Strategies: Participants for Aged and Disabled, 2000I. Increase HCBS Capacity

  • Expand public and private sources and revenues – waivers, private LTC insurance

  • Use payment and regulatory policies – cost-based HHA payment, incentives for residential care beds

  • Cover services in alternative residential settings

  • Expand functional and financial eligibility for HCBS


Three broad strategies ii constrain institutional growth
Three Broad Strategies: Participants for Aged and Disabled, 2000II. Constrain Institutional Growth

  • Regulatory approaches

    • Certificate of Need

    • Moratoria

  • Payment policies

    • Prospective payment for nursing facilities

    • Incentives for bed closure


Three broad strategies iii managed capitated ltc
Three Broad Strategies: Participants for Aged and Disabled, 2000III. Managed/Capitated LTC

  • Combine payment mechanisms and systems reform to

    • increase access to a wide array of HCBS

    • constrain overall LTC spending

      PACE, Social HMO

      Statewide approaches – e.g., Arizona

      Dual eligible programs: MN, NY, TX, WI


Which strategies appear most effective
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Increase capacity

    • Increase access through Medicaid funding

      • States have used 1915c waivers, home health & personal care to increase access. The number of participants, rates of use, and expenditures have each increased.

      • States with the highest per capita HCBS spending across all public sources rely almost exclusively on Medicaid. States with the lowest per capita HCBS spending underutilize Medicaid, relative to other states.

    • Suggests states should continue to increase capacity through Medicaid funding.


Which strategies appear most effective1
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Explore additional public funding sources

    • Increased use of Medicare funding is related to:

      • Greater per capita waiver participation

      • Greater per capita waiver expenditures

      • A larger share of long term care dollars supporting waiver services

      • Greater per capita HCBS expenditures

      • A larger share of long term care dollars supporting HCBS

    • Medicare and state funds are important sources of HCBS funds in certain states.

    • Suggests states should continue to explore additional public funds such as Medicare.


Which strategies appear most effective2
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Encourage purchase of private long term care insurance

    • Knowledge and information issues are important. However, the effectiveness of informational campaigns is unclear.

    • Affordability is key. A study of Maryland residents found that employer offering of private long term care insurance at an employer sponsored group rate more than doubled the probability of purchase.

  • Suggests states should pursue methods to make private LTC insurance more affordable (e.g., use of employer group rates, incentives to purchase). This is, however, a long term strategy.


Which strategies appear most effective3
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Expand HCBS capacity through payment and supply

    • Using a fee-for-service HHA payment is related to higher per capita 1915c expenditures and personal care expenditures

    • Increased supply of HHAs is related to:

      • Greater number of 1915c participants

      • Greater 1915c expenditures and HCBS expenditures

    • Regulation of HHAs has reduced the share of LTC dollars supporting both 1915c waivers and HCBS

  • Suggests states should continue to use payment and/or other incentives to expand supply.


Which strategies appear most effective4
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Expand HCBS capacity through payment and supply

    • MD CHHA per capita was 0.01 in 2000, (50 of 51)

    • Average CHHA per capita in U.S. was .032

    • MD CHHA per capita declined from 0.02 in 1990 (39 of 51)

    • MD has a certificate of need for HHAs, as do 19 other states

    • Access specifically to home health is a concern emerging from evaluations of the CMS Nursing Home Transition studies, state Olmstead activity, ADA complaints


Which strategies appear most effective5
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Increased availability of residential alternatives to nursing homes is related to:

    • Greater number of 1915c participants

    • Larger share of dollars supporting HCBS

  • Suggests states should continue to support services in residential alternatives to nursing home care.

  • MD -- 3.79 beds per capita in 2000 (18 of 51); U.S. average was 3.35 beds per capita in 2000

  • MD was 0.77 beds per capita in 1990 (40 of 51)

  • MD uses a 1915c waiver to provide services


Which strategies appear most effective6
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Constrain institutional growth

    • The more institutional beds in a state:

      • The lower a state’s per capita HCBS expenditures

      • The smaller a state’s share of long term care dollars supporting HCBS

      • The fewer 1915c waiver participants

      • The lower a state’s per capita 1915c expenditures

      • The smaller a state’s share of dollars supporting 1915c waiver

    • Effects of supply regulation less robust.

    • Suggests moderation of supply is important but that additional strategies, such as conversions should be explored.


Which strategies appear most effective7
Which Strategies Appear Most Effective? Participants for Aged and Disabled, 2000

  • Constrain institutional growth

    • MD had 5.72 NH beds per capita in 2000 (19 of 51, with 1 being best)

    • U.S. average was 7.06 beds per capita in 2000

    • MD had 5.63 NH beds per capita in 1990 (17 of 51)

    • MD has a certificate of need program in place, but not a bed moratorium; 21 states had a bed moratorium in 2000


Addressing state fiscal resources is key
Addressing State Fiscal Resources is Key Participants for Aged and Disabled, 2000

  • Grants to states for infrastructure (CMS Systems Change Grants)

  • Change Federal Matching Assistance Percentage (FMAP)

    • Recent precedent –Jobs Growth and Tax Relief Reconciliation Act of 2003

    • Tie FMAP increase to Olmstead activities

    • Adjust FMAP formula to account for state level differences in demand (e.g., percent 85+)


Cms money follows the person initiatives
CMS Money Follows the Person Initiatives Participants for Aged and Disabled, 2000

  • President’s Legislative Proposal - $1.75 billion Money Follows the Person Rebalancing Initiative to pay for HCBS for people leaving institutions to the community

  • 2003 $7 million Systems Change Demonstration Grants for Community Living to develop strategies to reform financing so funding can follow people from institutions to the community