Rebalancing Long-Term Care: New Mexico s CoLTS Program

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Rebalancing Long haul Care: New Mexico's "CoLTS" Program. May 28, 2009 Charles Milligan. Review. Foundation New Mexico's objectives and methodology in CoLTS Rhode Island's experience. - 2 - . Foundation.

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´╗┐Rebalancing Long-Term Care: New Mexico's "CoLTS" Program May 28, 2009 Charles Milligan

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Overview Background New Mexico's objectives and approach in CoLTS Rhode Island's experience - 2 -

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Dual eligibles expend a great deal of Medicaid and Medicare administrations, and the conveyance differs by administration . . . Source: The Hilltop Institute, 2008 Notes: Includes just constantly selected full-advantage duals with no gathering wellbeing scope; Nursing Facility figures likewise incorporate ICF-MR consumptions, and "Home Health" incorporates all Medicaid HCBS waivers

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In Maryland, between 1999-2008, 74 percent of all "discrete" nursing home affirmations started as Medicare stays . . . A DISCRETE STAY incorporates all days of care from admission to release in a solitary office Hilltop Refined MDS information for Maryland, 1999-2008

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. . . what's more, 84 percent of all "augmented" stays incorporate a Medicare traverse, for the most part toward the start. . . An EXTENDED STAY comprises of all adjoining discrete remains crosswise over offices (without any than a 30 day hole) Hilltop Refined MDS information for Maryland, 1999-2008

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. . . also, the underlying payer for most "developed stays" was Medicare. Ridge refined MDS information, Extended Stays in Maryland, 1999-2008

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Discharging inhabitants to the group requires early intercession . . . Purpose behind Discharge Days Hilltop Refined MDS information for Maryland, Extended Stays w/Discharge 1999-2008, constrained to the stays that change over to Medicaid

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. . . what's more, when numerous occupants change over to Medicaid, the chances of group reintegration are low. Days Hilltop Refined MDS information for Maryland, Extended Stays w/Discharge 1999-2008, constrained to the stays that change over to Medicaid

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New Mexico's Goals and Approach in CoLTS

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The Problem: Part 1, most NF remains that change over to Medicaid start as a Medicare post-intense stay 83 percent of all expanded stays start with Medicare as the payer After a 60-day length of stay, the chances of release to the group dip under 50 percent After a 60-day length of stay, the percent of individuals who in the long run change over to Medicaid first surpasses 50 percent

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Medicare program directors and the Medicare Advantage arranges frequently state that the Medicaid neglects to enough pay NFs, prompting to lacking staffing, prompting to avoidable hospitalizations paid by Medicare because of falls, weight ulcers, and pneumonia Medicare overseers affirm that restricted oversight by Medicaid offices of HCBS suppliers, and low installment rates for HCBS administrations, prompts to avoidable utilization of the ER and inpatient hospitalizations, which are paid by Medicare. The Problem: Part 2, Perceived Medicaid Cost Shifting to Medicare - 12 -

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Medicaid program directors frequently attest that Medicare program chairmen neglect to oversee doctor's facility releases, and neglect to oversee Medicare suppliers, prompting to avoidable costs in Medicaid because of long NF lengths of stay, and unmanaged Medicaid benefits requested by Medicare-paid doctors Medicaid heads state that excessively strict Medicare use administration improperly denies Medicare scope for home wellbeing, DME, along these lines prompting to cost moving to Medicaid The Problem: Part 3, Perceived Medicare Cost Shifting to Medicaid - 13 -

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And the open door: A planned program could enhance care and results. Facilitate (Medicare) doctor's facility release arranging with (Medicaid) people group based backings and administrations to dodge superfluous mulling in nursing offices Monitor nature of care in nursing offices to anticipate falls, weight ulcers, and different reasons for avoidable hospitalizations Coordinate Medicare home wellbeing, doctor, and Rx administrations with Medicaid specialist care, transportation, and HCBS waiver administrations for a very much composed group based arrangement of care - 14 -

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New Mexico, similar to Texas and Arizona, built up a compulsory program of composed long haul administrations ("CoLTS"). Figure 1 Capitated and Integrated Program Medicare CMS SNP All Benefits State Medicaid Dual Eligible States with deliberate projects: MN, MA, NY, WI, WA, FL vehicles: 1915(a)(c); 1915(a) States with required projects: TX, AZ, NM vehicles: 1915(b)(c); 1115 - 15 -

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New Mexico's objectives in its "Coordination of Long Term Services" (COLTS) program Promote people group based administrations by redirecting potential NF confirmations and shortening NF lengths of stay Promote adaptable advantage configuration to accomplish new models for group based administrations Improve quality through coordination of Medicare and Medicaid Achieve monetary investment funds by adjusting Medicare and Medicaid motivations - 16 -

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New Mexico's CoLTS display Mandatory program (in Medicaid) utilizing a 1915(b)(c) mix waiver Populations: All individuals who meet nursing office level of care All double eligibles Contracted Medicaid oversaw mind associations should likewise be statewide SNPs - 17 -

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Covered Services Long-Term Care Nursing office Waiver administrations Home Health Care Personal Care (w/purchaser direction choice) Acute Care Services Inpatient doctor's facility Outpatient clinic Pharmacy Physician Transportation Dental Excluded Services Behavioral wellbeing Indian Health Services and Tribal 638 administrations to Native American Members (uncommon exchange) COLTS secured administrations (and administration cut outs) - 18 -

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Prior to COLTS, New Mexico officially accentuated group based care . . . Medicaid Member Months (MMs) in Institutional Care and Community-Based Care in New Mexico, for individuals meeting nursing office level of care, SFY 2006 - 19 -

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. . . however New Mexico anticipates that COLTS will advance further rebalancing. Anticipated Medicaid Member Months (MMs) in Institutional Care and Community-Based Care New Mexico, SFY 2009 - 20 -

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. . . what's more, the outcomes are not yet in. CoLTS was propelled on August 1, 2008 Enrollment as of March 2009 was 26,540 Full statewide usage happened for the current month; add up to enlistment is approx. 38,000 Quality, get to, rebalancing, and cost data to be assessed soon.

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Rhode Island's Background

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Compared to the US, Rhode Island has more seniors, more seniors close destitution, and less seniors of shading RI US % of populace 65+ (2007) 13.9 12.6 % of populace 85+ (2007) 2.4 1.8 % of populace 65+ of shading (2007) 7.6 19.3 Median family unit wage, 65+ (2007) $28.2k $33.2k Source: AARP, "Over the States 2008: Profiles of Long-Term Care and Independent Living" - 23 -

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Compared to the US, Rhode Island has all the more nursing office beds, filled beds, seniors in nursing homes, and less individual and home wellbeing helpers RI US Nursing office beds/1,000 65+ 60 45 Nursing office inhabitance rate 92% 85% Nursing office inhabitants/1,000 65+ 56 38 Nursing office occupants/1000 75+ 104 78 Personal and home wellbeing associates/1,000 65+ 11 16 Source: AARP, "Over the States 2008: Profiles of Long-Term Care and Independent Living" - 24 -

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In Rhode Island, Medicaid covers 66% of all NF occupants, Medicare just covers 9%, and 26% are private or self-pay Distribution of Certified Nursing Facility Residents by Primary Payer Source, 2007 Source: Kaiser Family Foundation,, 2007 information - 25 -

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Rhode Island is underneath normal in HCBS members per 1,000 populace, however better than expected in the number served in a 1915(c) waiver. Rhode Island Medicaid HCBS Participants, by Program, 2005 Source: - 26 -

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Rhode Island has more double eligibles than normal, spends more on duals, and has a lower infiltration and take-up of SNPs. RI US % of Medicare recipients who are duals 23 21 % of Medicaid recipients who are duals 20 18 Average yearly Medicaid spending per dual $19,191 $14,972 Dual qualified enlistment in SNPs (starting at 5/09) 3,982 923,732 * United (916) * Blue Cross (3,066) Number of full advantage double eligibles 35,093 7.098 MM Approx. percent of double eligibles in a SNP 11.3 13.0 2005 information, other than SNP Sources:, 2005 information and - 27 -

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Opportunities in Rhode Island High institutional predisposition implies Larger per capita dollars accessible in capitation Significant opportunity to get better Higher than normal utilization of HCBS waivers Higher than normal % of duals Experience with oversaw mind Medicaid oversaw care may enhance take-up of SNPs. - 28 -

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Challenges in Rhode Island Low infiltration by Medicare Advantage SNPs Lower than normal limit with regards to individual care Lower than normal Medicare $$ in nursing homes - 29 -

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Contact Information Charles Milligan Executive Director The Hilltop Institute University of Maryland, Baltimore County (UMBC) 410.455.6274 - 30 -