Virginia’s Blueprint for Virginia’s Blueprint for the Integration of Acute the Integration of Acute

and Long-Term Care and Long-Term Care ServicesServices

The Second National Medicaid The Second National Medicaid CongressCongress

Cindi B. Jones, Chief Deputy DirectorDepartment of Medical Assistance Services

June 14, 2007

22

The Elderly And Disabled The Elderly And Disabled Represent 30 Percent of Program Represent 30 Percent of Program

RecipientsRecipients Demographics Of Recipients In Virginia’s Medicaid Program

Blind & Disabled20%

Adults

13%

Aged

10%

Children

57%

Note: Unduplicated count of recipients in FY 2005

30%

33

……Yet They Account For Three-Yet They Account For Three-

Quarters Of Program SpendingQuarters Of Program Spending

Children

Children

Adults

Adults

Blind & Disabled

Blind & Disabled

AgedAged

Expenditures

10%

20%

13%

57%

26%

45%

9%

21%

Recipients

30%

71%

Notes: FY 2005 recipient and expenditure data

44

This Obviously Means The Cost Of This Obviously Means The Cost Of Serving The Elderly and Disabled Is Serving The Elderly and Disabled Is Substantially Greater Than The Cost Substantially Greater Than The Cost

Of Care For ChildrenOf Care For Children

$1,725

$10,831

$3,109

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

Aged Blind &Disabled

All Recipients

Children Adults

Notes: FY 2005 recipient and expenditure data

$4,720

$11,595

55

Virginia’s Waiver Programs For The Elderly Virginia’s Waiver Programs For The Elderly And Disabled Are Expensive But Still Less And Disabled Are Expensive But Still Less

Costly Than Comparable Institutional CareCostly Than Comparable Institutional Care

$29,705

$23,904

$112,558

$27,537

$112,558

$56,116

131,246

$98,485

Per PersonInstitution $

Waiver Programs

AIDS DD MR Tech Assisted

EDCD

Per PersonWaiver $

$27,947

$18,305

66

DMAS’ Key LTC Performance Measure DMAS’ Key LTC Performance Measure Focuses on Community Based CareFocuses on Community Based Care

Community-Based Services as a % of Total Virginia Medicaid Long-Term Care

$

$200

$400

$600

$800

$1000

$1200

$1400

$1600

2001 2002 2003 2004 2005 2006

State Fiscal Year

$M

illi

on

s InstitutionalCare

Community-Based Care

29.5% 30.1%

31.9%

34.4%

36.2%

33.0%

77

Governor Kaine and General Assembly Governor Kaine and General Assembly Directs DMAS to Develop A Blueprint for the Directs DMAS to Develop A Blueprint for the

Integration of Integration of Acute and Long Term CareAcute and Long Term Care

2006 Virginia Acts of the General Assembly 2006 Virginia Acts of the General Assembly (Item 302, ZZ)(Item 302, ZZ)

This plan shallThis plan shall

• explain how the various stakeholders will be involved in the explain how the various stakeholders will be involved in the development and implementation of the new program development and implementation of the new program model(s);model(s);

• describe the various steps for development and describe the various steps for development and implementation of the program model(s), include a review implementation of the program model(s), include a review of other States’ models, funding, populations served, of other States’ models, funding, populations served, services provided, education of clients and providers, and services provided, education of clients and providers, and location of programs; andlocation of programs; and

• describe the evaluation methods that will be used to ensure describe the evaluation methods that will be used to ensure that the program provides access, quality, and consumer that the program provides access, quality, and consumer satisfaction. satisfaction.

88

DMAS Held a Series of Three Meetings on DMAS Held a Series of Three Meetings on Acute and Long Term Care Integration Models Acute and Long Term Care Integration Models

and Issuesand Issues (during Summer/Fall 2006) (during Summer/Fall 2006)

• First Meeting:First Meeting: Provided an overview of Medicaid Provided an overview of Medicaid funded acute and long term care services in funded acute and long term care services in Virginia and across the United States.Virginia and across the United States.

• Second Meeting:Second Meeting: Facilitated a meeting with Facilitated a meeting with stakeholders so they could provide input on the stakeholders so they could provide input on the options for developing an integrated acute and options for developing an integrated acute and long term care program in Virginia.long term care program in Virginia.

• Third Meeting:Third Meeting: Heard public comment on the Heard public comment on the integration of acute and long term care. integration of acute and long term care.

99

What is Integration?What is Integration?

Current System—fee for Current System—fee for service and fragmentedservice and fragmented

• Primary and Acute Care ServicesPrimary and Acute Care Services– PhysicianPhysician– HospitalHospital– PharmacyPharmacy– LabsLabs– Disease ManagementDisease Management

• Long Term Care ServicesLong Term Care Services– Nursing HomesNursing Homes– Home and Community Based Home and Community Based

Care Waiver programs (7)Care Waiver programs (7)– Case ManagementCase Management

New System—Managed care New System—Managed care and coordinatedand coordinated

• Combines all acute and long Combines all acute and long term care services (except for term care services (except for certain waiver programs) under certain waiver programs) under one capitated rateone capitated rate

• Combines Medicare and Combines Medicare and Medicaid fundingMedicaid funding

• ONE CALL—ALL CARE NEEDSONE CALL—ALL CARE NEEDS

• Right Services at Right TimeRight Services at Right Time

1010

Two Models for IntegrationTwo Models for Integration

• Community Model:Community Model: Program of All Inclusive Program of All Inclusive Care for the Elderly or PACE. Combines Care for the Elderly or PACE. Combines Medicaid and Medicare funding to provide all Medicaid and Medicare funding to provide all medical, social, and long term care services medical, social, and long term care services through an adult day health care center.through an adult day health care center.

• Six communities actively pursuing PACE—6 Six communities actively pursuing PACE—6 were awarded start up grants ($250,000 each).were awarded start up grants ($250,000 each).– Hampton Roads (2)Hampton Roads (2)– Richmond (1)Richmond (1)– Lynchburg (1)Lynchburg (1)– Far Southwest (2)Far Southwest (2)

1111

Two Models for Two Models for IntegrationIntegration

(continued)(continued)

• Regional Model:Regional Model: Could range from a Could range from a capitated payment system for Medicaid capitated payment system for Medicaid (potentially integrating Medicare (potentially integrating Medicare funding) for acute care costs with care funding) for acute care costs with care coordination for long term care coordination for long term care services, to a fully capitated system for services, to a fully capitated system for all acute and long term care services all acute and long term care services

1212

Development of a Plan:Development of a Plan:

Populations CoveredPopulations Covered All 234,945 Low-Income Seniors and Persons with All 234,945 Low-Income Seniors and Persons with

Disabilities (ABD)Disabilities (ABD)

• Medicaid Only (non-Medicaid Only (non-duals)duals) 86,732 clients 86,732 clients

– Don’t use long term care Don’t use long term care services (79,045 clients)services (79,045 clients)

– Use long term care Use long term care services (7,687 clients) services (7,687 clients)

• Medicaid and Medicaid and Medicare (dual Medicare (dual eligibles)eligibles) 148,213 148,213 clientsclients

– Don’t use long term care Don’t use long term care services (115,152 clients)services (115,152 clients)

– Use long term care Use long term care services (33,061 clients) services (33,061 clients)

1313

Development of a Plan:Development of a Plan:Services IncludedServices Included

• All Medicaid and Medicare primary, acute and long All Medicaid and Medicare primary, acute and long term care services (including nursing facility care and term care services (including nursing facility care and home and community based waiver services)home and community based waiver services)– Home health and personal care services will Home health and personal care services will

continue to be the cornerstone to keeping clients continue to be the cornerstone to keeping clients in their homes in their homes

• Services carved out:Services carved out:– Behavioral Health Services (state plan option only)Behavioral Health Services (state plan option only)– Certain waiver programs (MR, DS, DD, Technology Certain waiver programs (MR, DS, DD, Technology

Assisted) Assisted)

1414

Development of a Plan:Development of a Plan:Enrollment OptionsEnrollment Options

• Community Model/PACE:Community Model/PACE: Enrollment will be Enrollment will be voluntaryvoluntary

• Regional Model:Regional Model: Enrollment will be mandatory Enrollment will be mandatory for managed care programs for acute care for managed care programs for acute care needs only; enrollment will be voluntary for needs only; enrollment will be voluntary for managed care program for both acute and managed care program for both acute and long term care needs (clients will be enrolled long term care needs (clients will be enrolled and have the opportunity to opt out).and have the opportunity to opt out).

1515

Development of a Plan:Development of a Plan:ProvidersProviders

•Community Model: Community Model: Federal and Federal and state approved PACE sitesstate approved PACE sites

•Regional Models: Regional Models: Current Current managed care organizations managed care organizations and/or Medicare Advantage and/or Medicare Advantage Plans, Special Needs Plans Plans, Special Needs Plans

1616

Integration Models WillIntegration Models WillBe Phased InBe Phased In

• Community Model/PACECommunity Model/PACE– Current System:Current System: One Pre-PACE site more One Pre-PACE site more

than 10 years (Sentara Senior Community than 10 years (Sentara Senior Community Center)Center)

– Phase I (2007-2008):Phase I (2007-2008): Six full PACE sites Six full PACE sites• Two in Hampton Roads, One in Richmond, Two in the Two in Hampton Roads, One in Richmond, Two in the

far Southwest, One in Lynchburgfar Southwest, One in Lynchburg

– Phase II (2007-2009):Phase II (2007-2009):

• DMAS determines underserved areas of the state and DMAS determines underserved areas of the state and issues a Request for Application for additional PACE issues a Request for Application for additional PACE sites. Next site location is Northern Virginiasites. Next site location is Northern Virginia

1717

Integration Models WillIntegration Models WillBe Phased In Be Phased In (continued)(continued)

• Regional ModelsRegional Models– Current System:Current System: Managed care for acute care Managed care for acute care

needs only—49,000 ABDs with no Medicare and needs only—49,000 ABDs with no Medicare and with no long term care services.with no long term care services.

– Phase I (2007-2008):Phase I (2007-2008): Expands managed care Expands managed care for primary and acute care needs only to the for primary and acute care needs only to the ABDs with no Medicare but who have long term ABDs with no Medicare but who have long term care needs. LTC services remain fee for service. care needs. LTC services remain fee for service. • Will not include nursing facility residentsWill not include nursing facility residents• Will not include Technology Assisted Waiver clientsWill not include Technology Assisted Waiver clients• Will not move Will not move currentcurrent LTC waiver clients into managed LTC waiver clients into managed

care.care.

1818

Integration Models WillIntegration Models WillBe Phased In Be Phased In (continued)(continued)

• Regional ModelsRegional Models– Phase II (2008-2010):Phase II (2008-2010): Fully integrates acute and long Fully integrates acute and long

term care services and combines Medicaid and Medicare term care services and combines Medicaid and Medicare funding. funding. Excludes certain home and community-Excludes certain home and community-based care waiver program services (MR, DS, DD, based care waiver program services (MR, DS, DD, Tech) but does include the clients for coordination Tech) but does include the clients for coordination of acute and primary care services.of acute and primary care services.

• Next StepsNext Steps– Will include stakeholder input throughout the Will include stakeholder input throughout the

development and implementation of this phasedevelopment and implementation of this phase– Will develop a Request for Proposals in 2007Will develop a Request for Proposals in 2007– Will start as a pilot/regional program in 2008Will start as a pilot/regional program in 2008– Movement of populations, services, and funding sources Movement of populations, services, and funding sources

likely to be phased in over timelikely to be phased in over time