Aging and Long-Term Health Policy Mark R. Meiners Ph. D. Long-Term Care Educational Foundation

1. Aging and Long-Term Health Policy Mark R. Meiners Ph. D. Long-Term Care Educational Foundation National Capital Healthcare Executives January 14, 2014

2. 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

3. Coping with Chronic Conditions is Now the Norm in Health and Health Care • 1 in 4 Americans have a chronic illness • 54 million Americans have some level of disability • 50% of Adults 65 years old+ report limitations of activity • For adults 80 years old+ - 25% are in chronic care facilities - 40% need assistance with Activities of Daily Living

4. Chronic Care Challenges The health care system is increasingly complicated and difficult to use; The emergence of chronic illness is the major reason for medical encounters rather than acute care; Care coordination support is needed Transitions among providers can be improvement Patient Center Medical/Health Homes must become the norm Community based LTSS key part of quality improvement

5. Why is LTC such a Challenge? Assistance with ADL’s Monitoring & Support Care vs. Cure Physical and/or Cognitive Greater than 90 days

6. What is in a Name? Acute vs. Chronic illnesss Chronic Illness vs. LTC vs. LTSS Medical vs. Health vs. Social Services Disability vs. Frailty vs. Co-morbidity Seniors vs. Adult Disabled vs. DD vs. ID HCBS vs. Institutional Care vs. Assisted Living vs. Hospice

7. Incorporating LTC in Health Reform Chronic Care Improvement:  Care Coordination, Medical Home, House-call Primary Care, ACOs Investment in Safety Net:  HCBS alternatives to Institutional Care, Dual Eligible Integrated Care, Workforce Development LTC Financing:  Public Insurance, Private Insurance, Medicare and Medicaid System Reform

8. Why the Interest in LTC? • Multi-disciplinary focus - health, welfare, housing, transportation, etc. • Dramatic aging of the population suggests major structural changes in demand and supply of care. • Last big ticket item for which there is little insurance - a major cause of catastrophic costs leading to Medicaid

9. Who Pays for Long Term Care? (Home Care and Nursing Home) 30% Out-of-pocket 17% Medicare 7% Private Insurance 39% Medicaid 2% VA 5% Other Source: Health Care Financing Administration, 2004 statistics

10. What Does Medicare Say? Taken from an actual Social Security Statement

11. Long Term Care Financing Reform Options—Overview • Social Insurance—e.g., Medicare expansion. • Means tested—e.g., Medicaid improvements. • Public-private partnership—e.g., private financing options linked with public program reforms.

12. 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

13. History of LTC Insurance • Early 80's: research based awakening • Mid 80's: LTC insurance became real/so much so that it promoted a debate about the relative worth of social vs. private insurance • Mid 90’s: Medicare catastrophic, Pepper Commission, Clinton Plan, Contract with America, Partnership for LTC • Mid 00’s: 2005 DRA Partnerships, CLASS

14. 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

15. Why the Interest in Acute and LTC Integration? Important public financing considerations Cost shifting in both directions Unintended consumer consequences An opportunity to do better with limited resources Managed care implications Aging of the population/Chronic Care Imperative

16. 16 Picture the Problem: Medical and Social Service System Silos

17. 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

18. Village Research Goals Increase awareness of the importance of medical and social service coordination; chronic care needs Encourage teamwork between health and social service providers; Teach the value of patient empowerment; Teach providers and their patients how to identify and use available techniques, tools, and resources to better serve their patient care needs; Support care coordination among community providers.

19. Chronic Care Model Community Health System Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions 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 19

20. Evidence Based Decision Support Strategies • Medication self-management • Personal Health Record • Transition Tracking and Follow-Up • Knowledge of “Red Flags” Source: Tools booklet developed by Dr. Eric Coleman: MD, MPH; Care Transitions Program; Denver, Colorado 20

21. TEAM SAN DIEGO Goals Increase awareness of the needs of chronically ill elderly and disabled patients; Encourage teamwork between health and social service providers; Support care coordination among community providers; Teach the value of patient empowerment; Teach providers how to identify and use available techniques, tools, and resources to better serve their patients needs.

22. 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 3.0

25. Medical Home 1.0

26. Questions & Answers