Michigan LTC Conference: People. Partnerships, Possibilities

Michigan LTC Conference:Michigan LTC Conference:People. Partnerships, PossibilitiesPeople. Partnerships, Possibilities

Susan Nedza, M.D., MBASusan Nedza, M.D., MBAChief Medical OfficerChief Medical Officer

Region V-Centers for Medicare & Medicaid Region V-Centers for Medicare & Medicaid ServicesServices

US Department of Health & Human ServicesUS Department of Health & Human Services

March 23-24, 2006March 23-24, 2006

CMS AccomplishmentsCMS AccomplishmentsThe Disabled and Elderly Health Programs Group The Disabled and Elderly Health Programs Group

(DEHPG) under the Center for Medicaid and State (DEHPG) under the Center for Medicaid and State Operations Operations provides national leadership for the provides national leadership for the design of financially sound Medicaid programs.design of financially sound Medicaid programs.

DEHPG assists States in developing programs that DEHPG assists States in developing programs that support individuals of all ages and foster:support individuals of all ages and foster:

– long term care and pharmacy services;long term care and pharmacy services;

– full participation in community life and independent living; full participation in community life and independent living; andand

– economic self-sufficiency, and recovery.economic self-sufficiency, and recovery.

GUIDING PRINCIPLESGUIDING PRINCIPLES

DEHPG’s guiding principles in DEHPG’s guiding principles in delineating strategic plan goals are delineating strategic plan goals are to ensure:to ensure:– State flexibilityState flexibility– Accountability (program and personal)Accountability (program and personal)– Individual choiceIndividual choice

2006 DEHPG Strategic Action Plan

Vision:Vision: To transform the To transform the provision of provision of Medicaid servicesMedicaid services to support to support individual choices and preferences.individual choices and preferences.

2006 Strategic Action Plan2006 Strategic Action Plan

GOAL 1. ACCESS VIA PARTNERSHIPSGOAL 1. ACCESS VIA PARTNERSHIPS

Obj. A: Increase the support for and understanding Obj. A: Increase the support for and understanding

of program changes by of program changes by engaging stakeholders in engaging stakeholders in

developing policy.developing policy.

Obj. B. Increase beneficiaries’ access to the Part D Obj. B. Increase beneficiaries’ access to the Part D

Medicare Prescription Drug benefit through Medicare Prescription Drug benefit through working working

with States to wrap-around and support efforts with States to wrap-around and support efforts

to implement the Medicare Modernization Act to implement the Medicare Modernization Act

(MMA).(MMA).

2006 Strategic Action Plan2006 Strategic Action Plan GOAL 2: INNOVATION & FLEXIBILITYGOAL 2: INNOVATION & FLEXIBILITY

Obj. A: Obj. A: Increase beneficiaries’ access to Increase beneficiaries’ access to servicesservices and service options through problem and service options through problem solving and solution finding with States which solving and solution finding with States which results in program innovations and flexibility.results in program innovations and flexibility.

Obj. B: Obj. B: Increase support for State efforts to Increase support for State efforts to manage costsmanage costs while ensuring programs while ensuring programs operate in a manner consistent with law and operate in a manner consistent with law and regulations. regulations.


Goal #3: CHOICEGoal #3: CHOICE

Assist beneficiaries lead better lives by Assist beneficiaries lead better lives by advancing policies and programs that advancing policies and programs that facilitate individual choice and control, facilitate individual choice and control, and promote community living. and promote community living.


Goal #4: QUALITY- Goal #4: QUALITY- Improve the quality of Improve the quality of services beneficiaries receive by better services beneficiaries receive by better defining and advancing quality principles for defining and advancing quality principles for our programsour programs..Obj. A: Build States’ capacity for using quality Obj. A: Build States’ capacity for using quality elements and measures in order to continuously elements and measures in order to continuously improve each of our programs. improve each of our programs.

Obj. B: Improve responsiveness to States through Obj. B: Improve responsiveness to States through increasing administrative efficiency and ensuring increasing administrative efficiency and ensuring consistent program guidance and oversight.consistent program guidance and oversight.

CMS Quality and Efficiency

Agenda

Vision:Vision: To transform the To transform the healthcare healthcare system.system.

CMS Definition of QualityCMS Definition of Quality

The right care for every person every timeThe right care for every person every time. (at . (at the right place?)the right place?)

– This is a move from paying for what is medically This is a move from paying for what is medically necessary to appropriate.necessary to appropriate.

– What is “appropriateness?” What is “appropriateness?” Includes cost in the equationIncludes cost in the equation

TimingTiming

LocationLocation

Who will be paidWho will be paid

Medicare Value Based PurchasingMedicare Value Based Purchasing

The movement to pay for performance in The movement to pay for performance in all sectors is acceleratingall sectors is accelerating

Quality measurement will increasingly be Quality measurement will increasingly be tied to paymenttied to payment

Efficient provision of services will be Efficient provision of services will be rewarded.rewarded.

Value Based PurchasingValue Based Purchasing

Quality- at the patient levelQuality- at the patient level

Efficiency- at the system levelEfficiency- at the system level

Integration for payment for quality Integration for payment for quality strategies across the continuum of carestrategies across the continuum of care

LTC will be affected both actively and LTC will be affected both actively and passively by all of these initiativespassively by all of these initiatives

Nursing Home Pay for Performance Nursing Home Pay for Performance Demonstration Demonstration

Hospital-based and freestanding facilitiesHospital-based and freestanding facilities

Incentive payments on level of Incentive payments on level of performance and improvement over timeperformance and improvement over time

Objectives:Objectives:– Promote qualityPromote quality– Facilitate sharing of best practicesFacilitate sharing of best practices– Provide info to guide policy developmentProvide info to guide policy development

Potential Performance MeasuresPotential Performance Measures

MDS-basedMDS-based

Outcomes from state survey inspectionsOutcomes from state survey inspections

Staffing and stabilityStaffing and stability

Rate of Avoidable hospitalizationsRate of Avoidable hospitalizations

Others:Others:– Process of careProcess of care– Quality of lifeQuality of life– Resident satisfactionResident satisfaction

Deficit Reduction Act of 2005

DRADRABy 2030, spending for By 2030, spending for Medicare, Medicaid, and Medicare, Medicaid, and Social Security alone will be almost 60 Social Security alone will be almost 60 percent of the entire Federal budgetpercent of the entire Federal budget. .

The annual growth of entitlement programs The annual growth of entitlement programs needs to be slowed to affordable levels, but these needs to be slowed to affordable levels, but these programs do not need to be cut. programs do not need to be cut.

Reforms that can reduce the annual growth of Reforms that can reduce the annual growth of mandatory spending such as the mandatory spending such as the Deficit Deficit Reduction Act can save taxpayers nearly $40 Reduction Act can save taxpayers nearly $40 billion over the next five years .billion over the next five years .

DRADRA

The Deficit Reduction Act, together The Deficit Reduction Act, together with the with the Medicare Medicare Act of 2003, Act of 2003, require wealthier seniors to pay require wealthier seniors to pay higher premiums for their Medicare higher premiums for their Medicare coverage. coverage.

DRADRA

The DRA helps restrain The DRA helps restrain Medicaid Medicaid spending by reducing Federal spending by reducing Federal overpayment for Rx drugsoverpayment for Rx drugsThe bill also gives governors more The bill also gives governors more flexibility to design Medicaid benefits that flexibility to design Medicaid benefits that efficiently and affordably meet their efficiently and affordably meet their states' needs, tightens loopholes that states' needs, tightens loopholes that have allowed individuals to transferring have allowed individuals to transferring assets to their children so they can qualify assets to their children so they can qualify for Medicaid benefits.for Medicaid benefits.

DRA- DRA- Chapter 2 – LTC Under Chapter 2 – LTC Under MedicaidMedicaid

Subchapter A – Reform of Asset Transfer Subchapter A – Reform of Asset Transfer Rules - Rules - changes the start date for the period of changes the start date for the period of ineligibility for Medicaid LTC services, as ineligibility for Medicaid LTC services, as proposed in the President’s Budget. proposed in the President’s Budget.

This chapter curtail abuses in Medicaid LTC This chapter curtail abuses in Medicaid LTC by:by:– lengthening the look-back period to 60 monthslengthening the look-back period to 60 months– disqualifying individuals w/home equity over $500Kdisqualifying individuals w/home equity over $500K– Imposing partial months of ineligibilityImposing partial months of ineligibility– allowing states to accumulate multiple transfers into one allowing states to accumulate multiple transfers into one

penalty period penalty period

Sec. 6011. Lengthening look-back period; Sec. 6011. Lengthening look-back period; change in beginning date for period of change in beginning date for period of ineligibilityineligibility– This provision lengthens the “look-back” period This provision lengthens the “look-back” period

from 36 months to 60 months. from 36 months to 60 months.

– The “look-back” period is the amount of time for The “look-back” period is the amount of time for which states are required to determine whether which states are required to determine whether an individual transferred or gifted assets for less an individual transferred or gifted assets for less than fair market value. than fair market value.

– Gifting or transferring assets for less than fair Gifting or transferring assets for less than fair market value is one way individuals spend down market value is one way individuals spend down to become Medicaid eligible for long-term care. to become Medicaid eligible for long-term care.


Sec. 6012. Disclosure and treatment of Sec. 6012. Disclosure and treatment of annuities- annuities-

this provision requires states to make this provision requires states to make Medicaid LTC services contingent upon Medicaid LTC services contingent upon applicants disclosing a description of any applicants disclosing a description of any interest the individual or community spouse interest the individual or community spouse has in an annuity regardless of whether the has in an annuity regardless of whether the annuity is irrevocable or is treated as an annuity is irrevocable or is treated as an assetasset..


Sec. 6014. Disqualification for long-term Sec. 6014. Disqualification for long-term care assistance for individuals with care assistance for individuals with substantial home equitysubstantial home equityIndividuals shall not be eligible for LTC assistance Individuals shall not be eligible for LTC assistance if the individual’s equity interest in the individual’s if the individual’s equity interest in the individual’s home exceeds $500K. home exceeds $500K.

• The State may elect to change the $500K home The State may elect to change the $500K home equity limit to any amount up to $750K. equity limit to any amount up to $750K.

• The Secretary is to establish a process where this The Secretary is to establish a process where this requirement is waived in cases of demonstrated requirement is waived in cases of demonstrated hardship.hardship.


Sec. 6021. Expansion of State Long-Term Sec. 6021. Expansion of State Long-Term Care Partnership Program Care Partnership Program

The LTC Partnership program is currently The LTC Partnership program is currently operational in four states: operational in four states: California, California, Connecticut, Indiana and New York. Connecticut, Indiana and New York.

More than 180,000 long-term care insurance More than 180,000 long-term care insurance policies have been purchased in those policies have been purchased in those states, and it is estimated that through these states, and it is estimated that through these Partnerships, approximately $30 million of Partnerships, approximately $30 million of assets have been protected. The assets have been protected. The Partnership benefits consumers, Medicaid Partnership benefits consumers, Medicaid and private insurers. and private insurers.


This Chapter includes the Family Opportunity This Chapter includes the Family Opportunity Act, the Money Follows the Person Act, the Money Follows the Person Rebalancing Demonstration and other misc. Rebalancing Demonstration and other misc. provisions.provisions.

The Family Opportunity Act- The Family Opportunity Act- permits permits families with disabled children to buy into families with disabled children to buy into Medicaid, create demonstration grants for Medicaid, create demonstration grants for community-based alternatives to psychiatric community-based alternatives to psychiatric residential treatment facilities for individuals residential treatment facilities for individuals under the age of 21, and restores Medicaid under the age of 21, and restores Medicaid eligibility for certain SSI beneficiaries.eligibility for certain SSI beneficiaries.

DRA- Chapter 6 DRA- Chapter 6

This Chapter includes the Family Opportunity This Chapter includes the Family Opportunity Act, the Money Follows the Person Act, the Money Follows the Person Rebalancing DemonstrationRebalancing Demonstration

The Money Follows the Person (MFP) The Money Follows the Person (MFP) rebalancing demonstration rebalancing demonstration provides the provides the Secretary with the authority to award competitive Secretary with the authority to award competitive grants to States to pay for a period of 1 year an grants to States to pay for a period of 1 year an MFP-enhanced FMAP rate for the provision of MFP-enhanced FMAP rate for the provision of HCBS to individuals who transition from HCBS to individuals who transition from institutional long-term settings to home or institutional long-term settings to home or community-based settings of their choicecommunity-based settings of their choice..


This Chapter includes the Family Opportunity This Chapter includes the Family Opportunity Act, the Money Follows the Person Act, the Money Follows the Person Rebalancing Demonstration and other misc. Rebalancing Demonstration and other misc. provisions.provisions.

Other provisions Other provisions to assist the disabled in to assist the disabled in receiving care in the community include a receiving care in the community include a state option for expanded access to home state option for expanded access to home and community-based services for the and community-based services for the elderly and disabled andelderly and disabled anda state option for self-directed personal a state option for self-directed personal assistance services (cash and counseling). assistance services (cash and counseling).


Subchapter C – MiscellaneousSubchapter C – MiscellaneousSec. 6086. Sec. 6086. Expanded access to home and Expanded access to home and

community-based services (HCBS) community-based services (HCBS) Acting Acting through the Director of the Agency for Healthcare through the Director of the Agency for Healthcare Research and Quality (AHRQ), the Secretary Research and Quality (AHRQ), the Secretary shall develop program performance indicators shall develop program performance indicators and measures of client satisfaction for home and and measures of client satisfaction for home and community based services offered under State community based services offered under State Medicaid programs. Medicaid programs.

The Secretary shall use the indicators to assess The Secretary shall use the indicators to assess the outcomes of such services offered and make the outcomes of such services offered and make best practices publicly available. The provision best practices publicly available. The provision makes $1 million available for the period of makes $1 million available for the period of FY06-FY10 for research on HCBS quality.FY06-FY10 for research on HCBS quality.


ConclusionConclusion

Medicaid Reform will continue to affect the Medicaid Reform will continue to affect the long term care industrylong term care industry

Increasingly, value based purchasing will Increasingly, value based purchasing will become more prevalentbecome more prevalent

The Deficit Reduction Act will slow the The Deficit Reduction Act will slow the growth in Medicaid expenditures.growth in Medicaid expenditures.

THANK YOU!

Michigan LTC Conference: People. Partnerships, Possibilities

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