New York State Department of Health Office of Long Term Care: Current and Proposed Initiatives

1
New York State Department of HealthOffice of
Long Term Care Current and Proposed Initiatives

• Most Integrated Setting Coordinating Council
  (MISCC) Meeting
  
• January 23, 2008
• by
• Mark Kissinger, Deputy Commissioner
• Office of Long Term Care

2
Introduction

• Demographic projections reveal a five to ten year
  window of opportunity for planning and policy
  change to address future long term care (LTC)
  system demands.
• New Yorks LTC system is comprehensive but
  complicated with overlap among programs and
  services.
  
• The vast majority of LTC services are provided by
  unpaid families and neighbors.
  
• The projected growth among New Yorks elderly
  population will create increased demand for LTC
  services.
  
• New York and the nation will experience a decline
  in the number of potential caregivers over time.
  
• By 2030 total Medicaid LTC expenditures for
  residents aged 65 and older are projected to
  increase over 5 billion or 45.
  

3
Who Needs Long Term Care?

• In 2007, about nine million people in the U.S.
  over the age of 65 will need LTC by 2020, 12
  million older Americans will need LTC
  representing a 33 increase.
• It is expected that the population of New Yorkers
  age 65 years and older will increase by 30.4
  from 2000 to 2020.
  
• Most will be cared for at home family and
  friends are the sole caregivers for 70 of the
  elderly.
  
• A study by the U.S. Department of Health and
  Human Services indicates that people who reach
  age 65 will likely have a 40 chance of entering
  a nursing home.
• Source http//www.medicare.gov/LongTermCare/Stati
  c/Home.asp

4
Entry into the New York State Long Term Care
SystemWhat individuals of all ages, their
caregiver(s), and supports face
5
Spectrum of Long Term Care Services

• Informal Care
• Uncompensated care usually provided by a family
  member
  
• Non-Medical Services
• Homemaker services
• Home delivered meals
• Social day care
• Community Based Medicaid Services
• State Plan services examples personal care,
  certified home health agency services
  
• Waiver Service examples case management,
  assistive technology, respite
  
• Residential Options
• Assisted living program, assisted living
  residence, adult care facilities, continuing care
  retirement communities, and naturally occurring
  retirement communities
• Nursing Home
• Services provided in a skilled nursing facilities
  (SNF)
  
• End Of Life Care
• Hospice care including respite
• Available in hospitals, SNFs, hospice residences,
  palliative hospice care for children,and patient
  homes
  

6
Family and Informal Caregiving

• In 2001, SUNY Stony Brook conducted a statewide
  random telephone survey of family and informal
  caregivers to establish baseline data for New
  York State focusing on the population 60 and
  older.
• The survey indicated that 65 of those receiving
  care were aged 75 and older and 29 were aged 85
  and older.
  
• While state level data is not available, a
  national survey indicates that working age
  (18-64) recipients of unpaid care outnumber the
  elderly although they receive fewer hours of
  assistance.
• Compared to a national survey, New Yorkers tend
  to provide more care at the lower levels of
  intensity, possibly indicating a delay in
  entering the formal care system.
• For those individuals needing the lowest level of
  care, their needs were largely created from
  normal aging patterns. Those who were classified
  as needing the highest level of care largely
  suffered from chronic or major diseases.
• Source Farberman, H.A. (2001). Informal, unpaid
  care giving to New York State elders A telephone
  survey, 2001. Stony Brook, NY SUNY Stony Brook,
  School of Social Welfare.

7
Impact of Demographics on the Future Demand For
Long Term Care Services

• Baby Boomers have impacted all social systems.
  The LTC system is already impacted by the demands
  for services for parents of baby boomers.
  
• Other factors causing an increasing demand
  include increasing number of people with
  disabilities, low income and more individuals
  living alone.
• 20 of the 65 population will need more than
  five years of service and 40 will need more than
  two years of service.
  
• The following charts demonstrate the increasing
  potential demand for LTC services in New York by
  displaying the projected growth of the 65 and
  older population across the state. The elderly
  population will represent the greatest number of
  recipients of LTC, although a significant portion
  is also made up of a younger disabled
  population.
• Regional variation in demand and resources exist.
  All areas show a growth in the elderly population
  but some more than others.
  
• New Yorks projected rate of population growth
  compared to national benchmarks is significantly
  lower, allowing for a planned approach for
  changes in the LTC system.

8
Projected Dependency Ratio Who is Available to
Provide Support to the Growing Elderly in New
York State?

• The dependency ratio is calculated by dividing
  the number of the working age population by the
  combined young and elderly populations.
  
• A rising dependency ratio is a concern for areas
  that are facing an aging population, since it
  becomes difficult for social systems to provide
  for a significantly older, non-working
  population.
• The working age population often has dual
  commitments to those both younger and older,
  creating further strain on social systems.
  
• While New York City's dependency ratio will rise
  in in similar fashion to the rest of the state,
  it is projected to remain lower than the rest of
  the state and the nation as a whole.

9
New York State and the United States Populations
Will Experience a Decline in the Amount of
Potential Caregivers Over Time

• Note The dependency ratio is derived by
  dividing the 20 to 64 population by the combined
  under 20 and 65 and over populations.
  
• Source U.S. Census Bureau. (2004). Table 2a.
  Projected Population of the United States, by Age
  and Sex 2000 to 2050. and U.S.Census Bureau,
  Population Division, Interim State Population
  Projections, 2005.

10
Who Pays for Long Term Care?

• Total national spending for LTC is estimated at
  512.6 billion annually.
  
• Medicaid is the source of the majority of funds
  for formal long term care services both
  nationally and in New York State, estimated at
  101 billion and 14 billion respectively.
• New York spends nearly 8 billion for an array of
  home and community based programs and services
  and over 6 billion for skilled nursing
  facilities.
• Private payments to institutions, residential
  programs, home and community based services and
  LTC insurance add another element to the total
  annual New York expenditure estimated at over 40
  billion.
• The vast majority of services are provided
  informally by families and neighbors. The
  estimated annual market value is nearly 306
  billion nationally and 20 billion in New York
  State. The magnitude and implications of these
  expenditures and efforts are important to current
  and future policy.

11
Long Term Care Payer Mix and Expenditures
12
Medicaid Expenditures By Age

• New York State Institutional vs.
  Non-Institutional Long Term Care
  
• The average cost per recipient is 44,083 for
  institutional care and 21,653 for
  non-institutional care (about 51 less).
  
• Institutionalized young people have the highest
  average annual cost per recipient (86,191).
  
• The non-institutional average cost per recipient
  is significantly lower than institutional costs
  for all age groups but rises significantly from
  7,775 to 28,438 for those aged 65.
• New York State vs. Other States and U.S. Total
  Medicaid
  
• New York States percent of expenditures by age
  group exceeds the U.S. expenditures in every age
  group except 0-20.
  
• New York States average annual costs are
  significantly higher than the national average
  for 65, 75 and 85 groups.
  
• New York States average annual cost per
  beneficiary is higher than California, Texas,
  Florida and Michigan in every age group.
  

13
Home and Community Based Spending on Long Term
Care in New York Compared to Other States

• Nearly all states are working to make home and
  community based programs available to Medicaid
  recipients who need LTC, in an effort to keep
  individuals out of nursing homes and to save
  billions of dollars in Medicaid costs.
• Nursing homes can cost more than twice as much as
  home-based care. By relying more on home and
  community-based care, states can stretch their
  Medicaid dollars and serve more individuals.
• The national average for Medicaid spending on
  home and community based programs is 37.
  
• New York spends 42 of its Medicaid dollars on
  home and community based programs vs. nursing
  homes and intermediate care facilities for
  developmentally disabled and ranked number 15
  among all other states for fiscal year ended
  09/30/05.
• Oregon, New Mexico, Alaska, and Vermont spend
  more than 60 of their Medicaid dollars on home
  and community based care, whereas Mississippi
  spends less than 20 on home and community based
  care.
• Source http//www.hcbs.org/files/94/4693/FY2005I
  nstComm.xls

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New York Accounts for About 12 of all US
Medicaid Recipients of Home Health and Personal
Care (2004)

• Kaiser Family www. Statehealthfacts.org/comparetab
  le.jsp
  

15
New York Accounts for About 33 of all US
Medicaid Expenditures for Home Health and
Personal Care (2004)

• Kaiser Family www. Statehealthfacts.org/comparetab
  le.jsp
  

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System Summary

• New York State demographic projections for the
  aging population reveal a five to ten year window
  of opportunity for planning and policy change
  before the demand for LTC services and capacity
  is expected to dramatically increase.
• The solutions for upstate may be different than
  downstate due to geographical differences,
  transportation and workforce conditions. While
  the overall demand will be greater upstate, the
  rate of growth in demand will be greater
  downstate.
• Future elderly population growth will be a major
  driver in increased demand for LTC services.
  However, the LTC needs of the younger disabled
  population, while not anticipated to increase in
  a similar fashion, will continue to require the
  attention of policymakers.
• A comprehensive but complicated LTC delivery
  system currently exists in New York State with
  significant overlap and crossover among programs,
  services and settings.
• The lack of coordination among and transition
  between the informal, non-medical and medical
  systems is a major barrier to achieving
  efficiency.

17
System Summary

• There is a lack of consistency in how, when and
  where people with similar levels of needs are
  served.
  
• The vast majority of LTC services are provided
  unpaid by families and neighbors.
  
• The size of the contribution of private unpaid
  care giving and its impact on LTC is
  significant.
  
• The projected growth among New York's elderly
  population will create increased demand for LTC
  services. This, coupled with health care cost
  inflation rates, will result in an unsustainable
  level of Medicaid expenditures in the foreseeable
  future.
• By 2030, total Medicaid LTC expenditures specific
  to New York residents aged 65 and older are
  projected to increase over 5 billion or 45,
  from 11.4 billion to 16.5 billion.

18
Major Activities

• Implement Berger Commission recommendations.
• Refocus the work of the Long Term Care
  Restructuring Project to support the objectives.
  
• Support SOFA to complete point of entry and
  information and referral.
  
• Complete work of the Nursing Home Reimbursement
  Workgroup and collaborate with OHIP on payment
  reforms.
  
• Evaluate waiver programs for cost effectiveness,
  coordination and expansion (TBI, LTHHCP, CAH,
  etc.). Evaluate home care certification
  requirements.
• Approve additional 1,500 Assisted Living Program
  Beds.
  
• Complete review and application of Assisted
  Living Residences.
  

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Major Activities

• Increase marketing of Long Term Care Partnership
  and evaluate options for increasing
  participation.
  
• Implement NHTD Waiver and MFP initiatives.
  Complete SSI Study and develop proposals for
  consideration.
  
• Develop proposals to expand CCRCs.
• Support establishment of Palliative Care
  Initiatives.
  
• Evaluate Section 709.3-bed need methodology
  regulations.
  
• Address the training of workers.
• Emphasize Quality of Care processes at the
  Central Office and Regional Offices.
  
• Improve the discharge planning process through
  training, technical assistance and evaluation.
  

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Executive Budget Proposals To Be Released
January 22, 2008