Aging and Long-Term Health Policy
Mark R. Meiners Ph. D. Mark R. Meiners Ph. D.
Long-Term Care Educational FoundationLong-Term Care Educational Foundation
National Capital Healthcare Executives January 14, 2014
Economics of Aging and Long-Term Care
• Can we create a new way to pay for long-term care?
• Can we integrate acute and long-term care?
• Can we encourage informal care?
• Can we give people with disabilities maximum control over the services they receive?
• Partnership for Long-Term care
• Medicare/Medicaid Integration Program
• Service Credit Banking in MCOs
• Consumer Direction: Cash and Counseling
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Coping with Chronic Coping with Chronic
Conditions is Now the Norm in Conditions is Now the Norm in Health and Health CareHealth and Health Care
• 1 in 4 Americans have a chronic illness1 in 4 Americans have a chronic illness
• 54 million Americans have some level of disability54 million Americans have some level of disability
• 50% of Adults 65 years old+ report limitations of activity50% of Adults 65 years old+ report limitations of activity
• For adults 80 years old+For adults 80 years old+- 25% are in chronic care facilities- 25% are in chronic care facilities- 40% need assistance with Activities of Daily Living- 40% need assistance with Activities of Daily Living
Chronic Care ChallengesChronic Care Challenges• The health care system is increasingly complicated The health care system is increasingly complicated
and difficult to use;and difficult to use;
• The emergence of chronic illness is the major reason The emergence of chronic illness is the major reason for medical encounters rather than acute care;for medical encounters rather than acute care;
• Care coordination support is neededCare coordination support is needed
• Transitions among providers can be improvementTransitions among providers can be improvement
• Patient Center Medical/Health Homes must become Patient Center Medical/Health Homes must become the normthe norm
• Community based LTSS key part of quality Community based LTSS key part of quality improvementimprovement
Why is LTC such a Why is LTC such a Challenge?Challenge?
• Assistance with ADL’sAssistance with ADL’s• Monitoring & SupportMonitoring & Support• Care vs. CureCare vs. Cure• Physical and/or CognitivePhysical and/or Cognitive• Greater than 90 daysGreater than 90 days
What is in a Name? What is in a Name? • Acute vs. Chronic illnesssAcute vs. Chronic illnesss• Chronic Illness vs. LTC vs. LTSSChronic Illness vs. LTC vs. LTSS• Medical vs. Health vs. Social ServicesMedical vs. Health vs. Social Services• Disability vs. Frailty vs. Co-morbidityDisability vs. Frailty vs. Co-morbidity• Seniors vs. Adult Disabled vs. DD vs. Seniors vs. Adult Disabled vs. DD vs.
IDID• HCBS vs. Institutional Care vs. HCBS vs. Institutional Care vs.
Assisted Living vs. HospiceAssisted Living vs. Hospice
Incorporating LTC in Health Incorporating LTC in Health ReformReform
• Chronic Care Improvement: Chronic Care Improvement: Care Care Coordination, Medical Home, House-call Coordination, Medical Home, House-call Primary Care, ACOsPrimary Care, ACOs
• Investment in Safety Net: Investment in Safety Net: HCBS HCBS alternatives to Institutional Care, Dual alternatives to Institutional Care, Dual Eligible Integrated Care, Workforce Eligible Integrated Care, Workforce DevelopmentDevelopment
• LTC Financing: LTC Financing: Public Insurance, Private Public Insurance, Private Insurance, Medicare and Medicaid System Insurance, Medicare and Medicaid System ReformReform
Why the Interest in LTC? Why the Interest in LTC?
• Multi-disciplinary focus - health, welfare, Multi-disciplinary focus - health, welfare, housing, transportation, etc.housing, transportation, etc.
• Dramatic aging of the population suggests Dramatic aging of the population suggests major structural changes in demand and major structural changes in demand and supply of care. supply of care.
• Last big ticket item for which there is little Last big ticket item for which there is little insurance - a major cause of catastrophic costs insurance - a major cause of catastrophic costs leading to Medicaidleading to Medicaid
Source: Health Care Financing Administration, 2004 statistics
17%Medicare
(Home Care and Nursing Home)
39%Medicaid
30%Out-of-pocket
7%Private Insurance
2%VA 5%
Other9
Who Pays for Long Term Care?Who Pays for Long Term Care?
What Does Medicare Say?What Does Medicare Say?
Taken from an actual Social Security Statement
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Long Term Care Financing Long Term Care Financing Reform Options—OverviewReform Options—Overview
• Social Insurance—e.g., Medicare Social Insurance—e.g., Medicare expansion.expansion.
• Means tested—e.g., Medicaid Means tested—e.g., Medicaid improvements.improvements.
• Public-private partnership—e.g., Public-private partnership—e.g., private financing options linked private financing options linked with with public program reforms.public program reforms.
Economics of Aging and Long-Term Care
• Can we create a new way to pay for long-term care?
• Can we integrate acute and long-term care?
• Can we encourage informal care?
• Can we give people with disabilities maximum control over the services they receive?
• Partnership for Long-Term care
• Medicare/Medicaid Integration Program
• Service Credit Banking in MCOs
• Consumer Direction: Cash and Counseling
•Early 80's: research based awakening Early 80's: research based awakening
•Mid 80's: LTC insurance became real/so Mid 80's: LTC insurance became real/so much so that it promoted a debate about the much so that it promoted a debate about the relative worth of social vs. private insurancerelative worth of social vs. private insurance
•Mid 90’s: Medicare catastrophic, Pepper Mid 90’s: Medicare catastrophic, Pepper Commission, Clinton Plan, Contract with Commission, Clinton Plan, Contract with America, Partnership for LTCAmerica, Partnership for LTC
•Mid 00’s: 2005 DRA Partnerships, CLASSMid 00’s: 2005 DRA Partnerships, CLASS
History of LTC InsuranceHistory of LTC Insurance
Economics of Aging and Long-Term Care
• Can we create a new way to pay for long-term care?
• Can we integrate acute and long-term care?
• Can we encourage informal care?
• Can we give people with disabilities maximum control over the services they receive?
• Partnership for Long-Term care
• Medicare/Medicaid Integration Program
• Service Credit Banking in MCOs
• Consumer Direction: Cash and Counseling
Why the Interest in Acute and LTC Why the Interest in Acute and LTC Integration?Integration?
• Important public financing Important public financing considerationsconsiderations• Cost shifting in both directionsCost shifting in both directions• Unintended consumer consequencesUnintended consumer consequences• An opportunity to do better with limited An opportunity to do better with limited resources resources • Managed care implicationsManaged care implications• Aging of the population/Chronic Care Aging of the population/Chronic Care ImperativeImperative
16Picture the Problem: Medical and Social Service System Silos
Economics of Aging and Long-Term Care
• Can we create a new way to pay for long-term care?
• Can we integrate acute and long-term care?
• Can we encourage informal care?
• Can we give people with disabilities maximum control over the services they receive?
• Partnership for Long-Term care
• Medicare/Medicaid Integration Program
• Service Credit Banking in MCOs
• Consumer Direction: Cash and Counseling
Village Research GoalsVillage Research Goals
– Increase awareness of the importance of medical Increase awareness of the importance of medical and social service coordination; chronic care needsand social service coordination; chronic care needs
– Encourage teamwork between health and social Encourage teamwork between health and social service providers;service providers;
– Teach the value of patient empowerment;Teach the value of patient empowerment;
– Teach providers and their patients how to identify Teach providers and their patients how to identify and use available techniques, tools, and resources and use available techniques, tools, and resources to better serve their patient care needs;to better serve their patient care needs;
– Support care coordination among community Support care coordination among community providers.providers.
Informed,ActivatedPatient
ProductiveInteractions
Prepared,Proactive
Practice Team
Delivery
SystemDesign
Decision
Support
ClinicalInformation
SystemsSelf-
Management
Support
Health System
Resources and Policies
Community Health Care Organization
Chronic Care ModelChronic Care Model
Improved Outcomes
Figure 1 from Wagner, E.H. Chronic Disease Management: What Will It Take to Improve Care for Chronic Illness? Effective Clinical Practice, 1998; 1:2-4
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• Medication self-managementMedication self-management
• Personal Health RecordPersonal Health Record
• Transition Tracking and Follow-UpTransition Tracking and Follow-Up
• Knowledge of “Red Flags”Knowledge of “Red Flags”Source: Tools booklet developed by Dr. Eric Coleman: MD, MPH; Care Transitions Program; Denver, ColoradoSource: Tools booklet developed by Dr. Eric Coleman: MD, MPH; Care Transitions Program; Denver, Colorado
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Evidence Based Decision Support Strategies
TEAM SAN DIEGO GoalsTEAM SAN DIEGO Goals
– Increase awareness of the needs of chronically ill Increase awareness of the needs of chronically ill elderly and disabled patients; elderly and disabled patients;
– Encourage teamwork between health and social Encourage teamwork between health and social service providers;service providers;
– Support care coordination among community Support care coordination among community providers;providers;
– Teach the value of patient empowerment;Teach the value of patient empowerment;
– Teach providers how to identify and use available Teach providers how to identify and use available techniques, tools, and resources to better serve techniques, tools, and resources to better serve their patients needs.their patients needs.
Economics of Aging and Long-Term Care
• Can we create a new way to pay for long-term care?
• Can we integrate acute and long-term care?
• Can we encourage informal care?
• Can we give people with disabilities maximum control over the services they receive?
• Partnership for Long-Term care
• Medicare/Medicaid Integration Program
• Service Credit Banking in MCOs
• Consumer Direction: Cash and Counseling
24
Medical Home 3.0Medical Home 3.0
Remote Bio-metricMonitoring
Capable
HorizontallyIntegrated
WithInteroperable
HIT
CommunityHealth
SurveillanceInterfaces
Psycho/SocialEvaluation
AndIntervention
Patient E-Learning
Center
Connected to Community
ResourceDatabases
Community Practice
TranslationalResearch
Site
Advanced CareManagement
Capable
Fully E-Health Capable
Medical Home3.0
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Medical Home 1.0Medical Home 1.0
ElectronicMedical Record
Care Coordination
Capable
IndividualPatient Care
Plans
E-Prescribing
Medical Home1.0
Questions & AnswersQuestions & Answers
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