Medicaid Council Reports on AARP Solutions Forum on HCBS
November 19, 2013 03:25 PM
On October 30, 2013, The National Council on Medicaid Home Care – a NAHC affiliate – sent its Resource Center Director Steve Postal attended the AARP Solutions Forum: Modernizing Medicaid: Putting Home and Community-Based Services on Equal Footing with Nursing Homes. The following are the highlights of the Forum.
The Forum consisted of two panels. The first was a panel entitled Policies and Challenges and featured:
G. Lawrence Atkins, Long-Term Care Commission Staff Director; President, National Academy of Social Insurance;
Josefina Carbonell, Senior Vice President for Long-Term Care and Nutrition, Independent Living Systems LLC; and
Henry Claypool, Executive Vice President, American Association of People with Disabilities.
The second panel was entitled Learning from the States and featured:
Stephen Kaye, Professor, Institute for Health & Aging, University of California, San Francisco;
Charles Milligan, Jr. Deputy Secretary, Health Care Financing, Maryland Dept. of Health & Mental Hygiene; and
Jami Snyder, Operations Administrator, Acute and Long-Term Care, Arizona Health Care Cost Containment System.
Both panels were moderated by Susan Reinhard, Senior Vice President, AARP Public Policy Institute. Brief introductory remarks were given by Debra Whitman, Executive Vice President, AARP Policy, Strategy and International Affairs.
Panel 1: Policies and Challenges
Susan Reinhard commented that despite the continued institutional bias against home and community based services (HCBS), HCBS has made progress. Surveys consistently find that 9 out of every 10 people prefer HCBS to institutions. Some populations are doing better than others. 63% of Medicaid LTSS spending for younger people with disabilities went to the community, while only 28% of Medicaid LTSS spending for the elderly went to the community. For example, New Hampshire is doing better in rebalancing the intellectually disabled population, but not the elderly. HCBS utilization as a percentage of total LTSS expenditures is approximately 100% in New Hampshire for those with intellectual disabilities.
HCBS generally: Larry Atkins first provided some national and local developments regarding HCBS. Of those under 65, approximately 80% of those receiving LTSS are receiving HCBS. Atkins also mentioned that Tennessee was a great example of favoring HCBS, as it eliminated the institution as a de facto entry point into the Medicaid LTSS system, and instead instituted a preference for HCBS.
Waivers: Over 300 waivers help states achieve rebalancing, and these waivers require that those that receive HCBS have a level of acuity requiring institutionalization. By capping enrollment, the waivers give states flexibility to not provide some services to everyone that is eligible. Access becomes a concern as waivers are often open to a very small population, creating waiting lists. One recommendation is to streamline the waiver process (see bulleted list below for details), not to mandate state budget increases because of fiscal constraints.
Rebalancing Recommendations from the Commission: Atkins stated that rebalancing was one of the areas in the Long Term Commission that had broad support, although there was a difference of opinion as to the mechanisms needed to achieve rebalancing.
Atkins discussed some of the Commission’s recommendations, including that programs should:
Incentivize states to provide LTSS based more on need, rather than a first-come, first served basis;
Integrate LTSS with medical services, and prioritize HCBS;
Insure that individuals and caregivers can identify and make decisions regarding the choice between institutionalization and HCBS; and
Streamline the waiver process, i.e. reduce waiver complexity, streamline process in Medicaid waiver statute, and assist states in consolidating waivers with the aspiration towards universal waivers
The Commission did not recommend removing the institutional-level acuity requirement because of the uncertainty regarding the size of the population of beneficiaries eligible for HCBS.
Additional suggestions: Henry Claypool made a couple of additional suggestions. For example, he argued that the federal government and states should:
Re-invest in Money Follows the Person (MFP) and Balancing Incentive Payments Program (BIPP). He stated that if states don’t do this, they won’t have the structures to move forward with HCBS.
Streamline the state amendment process. He believes that the problem with HCBS is not so much in administering the programs but in the state plan amendments, which he felt are quite time consuming. So he advocates streamlining the process while preserving the integrity of the HCBS programs and dealing with competing demands of states to manage enrollments.
Josefina Carbonell explained that they were unable to achieve “parity” between institutional care and HCBS due to the “financial silos” caused by the various waivers.
Additional suggestions: Josephina made a couple of additional suggestions. For example, she argued that the federal government and states should:
Institute Medicaid financial and organizational reforms. Carbonell stated that the Medicaid payment reforms, in the form of capitation, global budgeting, and financial integration of Medicare and Medicaid in the duals demonstrations will bring further progress. She also emphasized the need to create partnerships with health plans, providers, and communities to bring together the knowledge and experience of the providers with the capital, technology, acute experience, and management skills of the health plans.
Use cost savings to promote rebalancing. Carbonell stated that policy makers are trying to reduce cost in addition to expand access. For example, in Choices for Independence, she found that she can reduce hospital admissions and ER visits, and use these savings to fund resources for rebalancing.
Increase investment in direct care workers. Carbonell also advocated improved compensation for direct-care workers. The goal should be not only to reduce the cost of care through rebalancing, but to also change the infrastructure to increase clinical outcomes, i.e. to incentivize home care workers. There is an opportunity to diversify the health care work force, and include lay caregivers, to improve quality. For example, in TennCare, the state looked at workforce as a mechanism to improve quality, and is developing training activities to increase quality of the workforce to help outcomes.
Emphasize financial integration over quality standards: Carbonell stated that with the duals demos, quality standards will eventually be in place, but initially the consumer must serve as the barometer of quality. Atkins added that financial integration is much easier than service integration. There are often no standards for home care workers in most states, and it is very difficult to devise quality standards for LTSS. He suggested putting the financial incentives in place first, and then focus on quality.
Panel 2: Learning from the States
HCBS numbers “a landmark, not a destination.” According to Steve Kaye, the population needing LTSS in the community (11 million, or 5.4 million that just need assistance with activities of daily living) far outnumbers the institutional population (1.7 million). Medicaid expenditures of LTSS are currently 45% home and community, and 55% institutional. However, it is important to note that because so many more people are living in the community, crossing the 50% threshold for HCBS is a landmark, not a destination.
Rebalancing varied. Breaking it down by states, there is huge variation in HCBS utilization. Mississippi only spends 22% of its Medicaid LTSS expenditures on HCBS, while New Mexico spends 91%.
ID/DD vs. non-ID/DD populations. Kaye stated that the ID/DD population reached 50% expenditures in HCBS in 2000. There are currently states that spend 0% in institutional ID/DD. Since 1999, Alaska has had no Intermediate Care Facilities for individuals with Mental Retardation (ICF/MR facilities), or institutional facilities for people with intellectual and developmental disabilities. Mississippi, on the other hand, currently spends 14% of its Medicaid LTSS ID/DD expenditures on institutional care. The non-ID/DD population, i.e. aged, disabled, and other, has been much slower to rebalance. By 2010, only 35% of Medicaid LTSS non-ID/DD expenditures went to HCBS, while 65% went to institutional care. While the 35% was a marked increase from 20% in 2000, this is far from the 50% landmark.
Arizona’s Agency with Choice Model
Modified self-directed care. Jami Synder talked about the Arizona model, Agency with Choice, which began in January. It is a hybrid between self-directed and traditional attendant care. It is a partnership arrangement where responsibilities are delineated between beneficiaries and providers/agencies. For more information on Agency with Choice, including a link to frequently asked questions, click here.
HCBS and ROI. Since 1998, there has been a 40% increase in HCBS placement (not including the ID/DD population) in Arizona, resulting in over $300 million in savings.
Success factors. Synder felt that the key factors that maintain the integrity of HCBS placement in managed care include:
Having an integrated service delivery model which coordinates LTSS with acute care and behavioral health;
Establishing a rate setting mechanism which incentivizes HCBS. Arizona has a blended capitation rate which does just that;
Establishing clear cut network standards;
Establishing clear quality standards, which for Arizona includes case management standards and training for direct-care workers; and
Establishing “system flexibilities” for the varied needs of the beneficiaries.
Cost-effectiveness measure. What has helped in Arizona is a requirement that for every individual receiving LTSS, expenditures cannot exceed what expenditures would have been in an institutional setting. These benchmarks vary by population; since the cost of care in an ICF is greater than a NF, the benchmark for the ID/DD population is higher than that of the non-ID/DD population.
ACA Financial Incentives and Obstacles. Charles Milligan talked about the financial incentives and obstacles in the ACA . For financial incentives, he stated that Maryland was using Community First Choice (CFC) (which provides enhanced federal funding for personal care in the community-Maryland will launch this January 1); Money Follows the Person (MFP) (which Maryland has had for some time), and Balanced incentives Payment Program (BIPP)(Maryland received a $106 million grant to be used through September 2015 to automate home care systems and plans of care). Milligan discussed numerous challenges, including:
With MFP, getting high enrollment given that the program does not pay for housing. He expressed that finding resources to pay for room and board is a challenge for all programs;
With BIPP, The main challenge he stated was that with such a uniform assessment instrument, he found that normalizing hours and supports with different levels of acuity and plans of care is challenging;
On the positive side, for BIPP, MD incorporated a program integrity piece through a mechanism that makes sure that the workers were in attendance in the homes as a condition to secure payment.
Supporting self direction while also working with collective bargaining, as SEIU and AFSCME are trying to negotiate rates;
Eligibility rules still favor institutional care, as HCBS programs do not pay for room and board; and
The absence of meaningful long term care private insurance.
Merging waivers: Another thing that Milligan said was critical was the need to merge waivers. But he questioned how this would be accomplished. At present, people are taken off the waitlists on a first come first served basis, but often those that get waivers are pretty stable. Should a state issue waivers based on acuity, i.e. those that are at the greatest risk of institutionalization?
ROI for HCBS. Milligan said that in general, HCBS saves money. But breaking down the populations shows a more nuanced analysis. For ID/DD population, in 1992, there were 62,000 people receiving HCBS, and by 2010 that number was 600,000. While residents in ICF/MR facilities decreased during that period from 140,000 to 90,000, overall LTSS costs increased by 52% from 1995 to 2009. However, the cost for the non-ID/DD population as been relatively consistent, adjusting for inflation, despite the number of HCBS recipients increasing.
Paying informal caregivers. Milligan raised the issue of paying informal caregivers. Debra Whitman had stated in her introductory remarks that there were 45 million caregivers in the US, which comprised an “invisible army” of uncompensated friends and family. Milligan stated that there are published studies to indicate that informal caregiving amounts to an estimated $750 billion/year that is spent from friends and family members in work hours and other resources. This is a bargain for MD, but a good assessment to figure out who is able to provide safe care safely is needed, or else greater institutionalization and thus greater costs become risks.
For a link to AARP’s website, including a full transcript of the Forum, click here.
Streamlining HCBS approval processes. The National Council on Medicaid Home Care agrees with the speakers of the Forum in that streamlining the HCBS approval process will further increase access to HCBS, either by improving the waiver process, as Larry Atkins suggested, or the state amendment process, as Henry Claypool suggested.
Incentivize HCBS. The Council supports greater incentives for HCBS. Incentivizing HCBS will further improve availability of these services, as stakeholders will be more motivated to participate in rebalancing. Arizona’s cost effectiveness measure and rate setting mechanism, discussed above, in addition to South Carolina’s recent financial incentives to both providers and plans in the state’s dual alignment MOU, are examples of this.
Lack of funding mechanisms for HCBS concerns Council. While the Commission agreed on the importance of HCBS, perhaps the most critical element---funding of HCBS, was not agreed on. The refusal of the Commission to mandate state budget increases for HCBS is a missed opportunity, as beneficiaries vie for scarce resources, often in waitlists. The Council advocates that the federal government and the states provide further mechanisms to increase funding for HCBS.
To see a previous Council article on the findings of the Commission, click here.
The Council encourages providers to continue advocating for mechanisms to improve access to HCBS services through their state associations, as well as through state and federal governments. Home care providers are encouraged to keep abreast of HCBS developments in their states, and nationally, and to contact the Council with any questions or concerns.