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HMA HealthManagement.com
September 23, 2015
21st Century LTSS: A Roadmap to Improved
Outcomes, Lower Costs and Better Lives for
Individuals with Complex Healthcare
Needs
Speakers: Ellen Breslin, Senior Consultant, HMA
Dennis Heaphy, Health Policy Analyst, Disability Policy Consortium
Moderator: Carl Mercurio, HMA Information Services
HMA
Welcome
• Advocates
• Firms and Foundations
• Providers, Plans, and ACOs
• State and Federal Agencies
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HMA
Overview of Today’s Webinar
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Introduction: 21st Century LTSS
Section 1. Progress, and Realities
Section 2. Outcome Reform: Define Quality
Section 3. Payment Reform: Pursue Value-Based Purchasing
Section 4. Final Thoughts
HMA
INTRODUCTION: 21st CENTURY LTSS
1. Significant progress thanks to the ADA, Olmstead, new laws and regulations, new programs, greater understanding of social determinants. HCBS represents 51% of total LTSS expenditures, first time ever.
2. Opportunities under payment and delivery reform to improve the quality of LTSS, to bend the cost curve. Value over volume. New investment dollars. Value-based purchasing, shared savings, and bundled payments.
3. Leverage the payment and care delivery reform to facilitate progress. Action steps: (1) Ensure beneficiary control and choice; (2) Invest in LTSS providers/partners and Community Based Organizations, including making them part of new governing structures; (3) Create new outcome measures to link to payments (value over volume); (4) Pursue value-based purchasing using new outcome measures; and, (5) Minimize LTSS and CBO financial risk, payment accuracy through risk adjustment.
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Today’s Webinar: Key Questions
Today’s webinar will provide you with an introduction into the relationship between the changing landscape and LTSS. In preparing this webinar, we considered the following questions:
1. How do we take LTSS to the next level?
2. How do we leverage LTSS to improve outcomes, bend the cost curve, and improve lives?
3. What is the process for creating a robust primary care strategy?
4. What does a “fresh conceptualization” of LTSS look like?
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HMA
SECTION 1. PROGRESS, AND REALITIES
From ADA to Olmstead to Medicaid
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HMA
Fresh Conceptualization
CMS Proposed LTSS Definition, “services and supports provided to beneficiaries of all ages who have functional limitations and/or chronic illnesses that have the primary purpose of supporting the ability to live or work in the setting of their choice, which may include the individual’s home, a provider-owned or controlled residential setting, a nursing facility, or other institutional setting.”
“Fresh Conceptualization,” speaks to providing person-centered care that includes, but is not limited to: (1) Beneficiary driven, (2) “Advances” beneficiary’s ability to live and/or work and reside in a setting of his or her choice (Justice in Aging), (3) Seeks to reduce disparities in health outcomes by addressing health disparities at the community level, (4) Maximizes care team level authority, minimizing utilization management, (5) Includes conflict-free case management, (6) Is uniformly adopted by states and MCOs Or analogous definitions developed by states and MCOs (DREDF).
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HMA
HCBS Majority of Total Medicaid LTSS
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First Time Ever: HCBS Tipped 51% of All LTSS Spending. Will reductions in use of hospital and nursing facility under payment and care delivery
reform lead to increases in the proportion of LTSS spent on HCBS? How far can we go?
Medicaid 1995 2005 2013 2025
Institutional 82% 63% 51% 35%
HCBS 18% 37% 49% 65%
Total LTSS 100% 100% 100% 100%
Percentage point shift in HCBS 19% 12% 16%
Source: Percentages for 1995, 2005, and 2013, based on data from CMS, June 30, 2015.
Percentage of Total Medicaid LTSS Expenditures
HMA
Very Big Numbers; Importance of Quality of Life
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1. LTSS Spending. Total spending on LTSS was about $220 billion in 2012, representing 9% of personal health care spending. Medicaid spending represented 61% of the total spent on LTSS.
2. Persons with disabilities. 1 out of 5 persons or 20 percent of the US population has a disability. Adults and seniors comprise 90% of the population of those with a disability.
3. Persons with disabilities fare worse by all measures than persons without a disability. higher rates of poverty, unemployment, housing difficulties than persons without disabilities. The rates of chronic disease such as high blood pressure and obesity are higher.
The CDC calculated a rate of 22% among adults only, and reports that the two groups that are most significantly affected are women (1 in 4) and non-Hispanic Blacks, (3 in 10). Note that ACS reports a rate of 12.7% for the entire US population, which is lower than the 18.7% shown on the table above.
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Persons With and Without a Disability
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Statistic
With
Disability
Without
Disability Difference
Persons with disabilities fare
worse on these measures:
Income/Living conditions
Living in poverty 0.29 0.14 0.15 More than 2 x greater
Median Earnings 20,785$ 30,728$ (9,943)$ Earn about one-third less
Employment, persons living in the
community 18-64 years of age 0.34 0.74 (0.40) Half the rate of employment.
Health
Smoking 0.25 0.16 0.09 About 1.5 x greater
Obesity 0.40 0.25 0.15 About 1.5 x greater
High Blood Pressure 0.42 0.26 0.15 More than 1.5 x greater
Be Inactive 0.36 0.24 0.12 About one-third greater
Source: 2014 Disability Statistics Annual Report. All US Civilians.
Source: CDC, 2015, Adults only.
Statistics About US Population
HMA
LTSS Performance In State Context Close up of States Ranked #1 and #51, US Average
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The state landscape is quite different for the #1 LTSS performing state and the #51 LTSS performing state.
16.4%
10.7%
5.3%
87.0%
73.6%
22.2%
14.8% 13.0%
90.0%
51.3%
29%
18%
7.9%
73%
41%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Disability rate Poverty rate % Black or African American SSI % 1 Bedroom $ Medicaid: HCBS % of LTSS
State LTSS Performance and State Landscape
State #1 US State #51
Data sources include: The SCAN Foundation 2014 LTSS Scorecard, US Census Bureau, Technical Assistance Collaborative, CMS.
HMA
LTSS Performance In State Context States Grouped by High and Low Performance, US Average
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As a group, the lowest performing states have higher rates of disability, poverty rates, and African Americans, with better ratios of SSI income to housing costs, and lower spending on HCBS as a proportion of total Medicaid LTSS spend.
Data sources include: The SCAN Foundation 2014 LTSS Scorecard, US Census Bureau, Technical Assistance Collaborative, CMS.
19.4%
12.0%
3.9%
98.0%
68.1%
22.2%
14.8% 13.0%
90.0%
51.3%
28.7%
16.9% 17.6%
79.4%
38.8%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Disability rate Poverty rate % Black or African American SSI % 1 Bedroom $ Medicaid: HCBS % of LTSS
State LTSS Performance and State Landscape
High Performance (5 states) US Low Performance (5 states)
HMA
Levers and Mechanisms To Improve Performance and Quality of Life
1. Levers
• Better health outcomes
• Quality of life
• Reduced administrative costs
• Improved provider relations
• Potential savings, lower hospital use
2. Mechanisms
• Provider/care team autonomy
• Reduce reliance on prior approval and utilization management
• Create new outcome measures
• Invest in LTSS and Community Based Organizations
• Pursue value-based purchasing
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HMA
Poll #1
How is your state ranked, according to the LTSS Scorecard?
1. Among the states ranked in the top 10
2. Among the states ranked in the top 25
3. Among the states ranked in the bottom 25
4. Don't know
5. Not applicable
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SECTION 2. OUTCOME REFORM
PART I OF THE ROADMAP
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Outcome Reform
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1. Goal of “outcome reform” is to create new outcome measures that facilitate the best outcomes for persons with disabilities.
2. The Commonwealth Fund report, March 2014, reports “quality of life measures notably lacking” as are “informative standardized measures of long-term services and supports.”
3. Quality must include measures of control, choice, person-centered care, beneficiary agency as well as activation and health outcomes. Value must be understood in more than just financial terms, and savings. LTSS encompasses quality of life.
4. Outcome reform is key to value-based purchasing, which is predicated on the assumption that we can link payments to outcomes. We need to have the right outcomes.
HMA
Outcome Measures to Match Beneficiary Priorities
1. “Value-Based Payments Require Valuing What Matters to Patients” (JAMA, 9/15)
• Secretary of Health and Human Services, Sylvia Burwell, “recently announced the department’s intention to tie most Medicare fee-for-service payments to value by 2018.”
• “A high-value health care system would identify each individual’s priorities and measure the fidelity with which those priorities are met.”
• “How can a care system be structured to deeply respect the myriad differences among patients when disabilities or advanced age makes those differences especially important? The answer is that the delivery system must proactively help affected people articulate their priorities and goals.”
2. Beneficiaries need:
• Identified goals AND person-centered metrics to be used as part of quality metric mix
• Choice of providers
• Control over how AND where services are provided
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HMA
Poll #2
Does your state have standardized requirements across MCOs for the provision of LTSS?
1. Yes
2. No
3. Don’t Know
4. Not applicable
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SECTION 3. PAYMENT REFORM
PART II OF THE ROADMAP
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HMA
Payment Reform
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1. Goals of “payment reform” are many.
• Improve outcomes
• Quality of life
• Bend the cost curve, pay for value over volume
2. What will it take?
• Collaboration among a diversity of providers
• Investment into LTSS providers and CBOs
• Effective use of value-based purchasing
HMA
Implementing the Vision Positioning LTSS & CBOs for Value-Based Purchasing
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Payment and care delivery reform will lead to opportunities to invest and reward providers, such as is happening in NY. Newly created entities under care delivery reform, for example, must distribute funds to achieve outcomes. How will investment funds be used to create a robust primary care infrastructure? Which providers will receive funds? Should LTSS and CBOs receive funds directly from new entities, or serve as downstream providers?
New entity
Medical LTSS CBOs
Investment
HMA
Implementing the Vision VBP, From Simple to Complex
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1. Value-based purchasing decisions
• Eligible providers/partners
• Desired outcomes
• Data to measure outcomes against baseline
2. Complexities of value-based purchasing
• The development of goals that include benchmarks for addressing health indicators and social determinants of health through robust LTSS.
• The creation of a methodology that favors quality of life measures, even if the ROI is not obvious.
• Rewards for providers who invest in CBOs that provide LTSS and other community services.
HMA
SECTION 4. FINAL THOUGHTS
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The Roadmap in Very Broad Terms.
1. Create goals to improve consumer control and choice, prevent secondary disabilities, lower hospital use.
2. Leverage opportunities under payment and care delivery reforms.
3. Action steps: (1) Ensure beneficiary control and choice, (2) Invest in LTSS providers/partners and Community Based Organizations, including making them part of new governing structures, (3) Create new outcome measures to link to payments (value over volume), (4) Pursue value-based purchasing using new outcome measures, and, (5) Minimize LTSS and CBO financial risk, payment accuracy through risk adjustment.
4. Invest in payment accuracy through risk adjustment, why it is important.
HMA HealthManagement.com
September 23, 2015
Q & A
Ellen Breslin, Senior Consultant, HMA
Dennis Heaphy, Health Policy Analyst, Disability Policy Consortium [email protected]
