The Hilltop Institute was formerly the Center for Health Program Development and Management.

New Mexico’s Coordinated Long-Term Services (CoLTS)

Program

February 25, 2009

Charles Milligan

Medicaid Managed Care Summit

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Overview

Portrait of Dual Eligibles

Portrait of Long-Term Care

The Problem, and New Mexico’s approach in CoLTS

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Portrait of Dual Eligibles

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Dual eligibles are predominantly female, and span all age groups

Female62%

Male38%

Under 65(disabled/ ESRD)

39%

65-74 years26%

75-84 years

23%

85+ years13%

Gender Age group

Source: MedPac, June 2008; based on data from the 2005 MCBS

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Hispanic

White, Non-Hispanic

57%

Black, Non-Hispanic

19%

15% Other9%

Race/ethnicity

Below poverty

53%

100-125% FPL21%

125-200% FPL19%

Over 200% FPL6%

Income status

Source: MedPac, June 2008; based on data from the 2005 MCBS

Dual eligibles are disproportionately white, and poor

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Overall, Medicare beneficiaries are generally healthy . . .

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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

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Even though they have Medicaid, dual eligibles cost Medicare more than other Medicare beneficiaries . . .

Dual 16%

Non-dual84%

Dual25%

Non-dual75%

Medicare enrollees by eligibility, 2005

Medicare spending by eligibility, 2005

Source: MedPac, June 2008

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. . . in all major services . . .

Source: MedPac, June 2008

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. . . and dual eligibles also use all services at a higher rate.

Source: MedPac, June 2008

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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

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. . . 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

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. . . 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

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InpatientHospital

InpatientHospitalInpatientHospital

Dual Eligibles: Medicare serves as a clinical gateway to Medicaid

Medicaid-Covered

OutpatientServices

NursingFacility

MedicaidBenefits

MedicareBenefits

Physician

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Portrait of Long-Term Care

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

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

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Medicaid is the largest payer for nursing home care.

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

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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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For “extended stays,” the vast majority of initial NF admissions came from a hospital . . .

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

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. . . and the initial payer was Medicare.

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

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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

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. . . 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

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The Problem, andNew Mexico’s 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

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

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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.

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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. . . and dollars.

New Mexico (#2) $173,587,539 39.3% $268,067,798 60.7% $441,655,337Michigan (#36) $1,482,976,417 81.0% $348,501,735 19.0% $1,831,478,152United States $46,980,338,539 69.0% $21,129,494,817 31.0% $2,273,133,489

Nursing home data for several states include expenditures for Medicaid Upper Payment Limit programs.Please see the accompanying report for additional information regarding these data.

Distribution of Medicaid Long Term Care Expenditures for A/D services

STATETOTAL

LTC Expenditures

Institutional vs. Community-Based Services, FY 2007

% of Medicaid LTC ExpendituresExpenditures % of Medicaid LTC

Community-Based Services

5 Data for Tennessee do not include home health provided in a managed acute care program

4 Mississippi A/D waiver data are not available because the state did not report target population information for HCBS waivers.

Institutional LTC Services

Institutional services include nursing home services. Community-based services include personal care, home health, HCBS waiver services for older adults and people with physical disabilities, Section 1115 Waivers that provide HCBS targeting older adults and people with physical disabilities, and HCBS authorized under Section 1929.

2 California's reported expenditures will likely increase as the state submits prior period adjustments. For FY2002 through FY2005, adjustments increased community services expenditures by $500 - $800 million.

1 Data for Arizona, Florida, Massachusetts, Minnesota, New York, Texas, and Wisconsin do not include managed LTC expenditures.

3 Vermont data do not include a program that covers both long-term and acute care because long-term care spending data are not available.

Source: Burwell and Eiken, “Distribution of MedicaidLong-Term Care Dollars, FFY 2007”

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

1 2 3 4

Group Group Description Percent of Total MMs

Transition Goal

(% of MMs)

Average NFMMs

SFY 2006

TransitionedIndividuals – Avg. NF MMs

1 Full Year 63.1% 10% 12.0 5.0

2 New Arrivals 12.4% 15% 6.2 2.5

3 Discharged to Community

9.5% 20% 6.1 1.5

4 Eligibility Ended 6.4% n/a 6.1 n/a

5 Short Stay 3.4% n/a 3.2 n/a

6 Short Out, Hospital 3.1% n/a 10.1 n/a

7 Short Out, Community 2.1% 20% 5.0 4.0

NF Transition Goals for COLTS in Year 1 (SFY 2009)

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. . . 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 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

Full statewide implementation will occur in a few months

Quality, access, rebalancing, and cost information to be evaluated soon.

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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