The Future of LongTerm Care and the Aging Network: Ethics and Efficiency in LongTerm Care

1
The Future of Long-Term Care and theAging
Network Ethics and Efficiencyin Long-Term Care

• Larry Polivka, Ph.D.
• ASA/NCOA Conference
• Anaheim, CA
• March 17, 2006

2
Creating a Balanced Long-Term Care System
Organizational and Administrative Options

• Our major LTC policy goal should be to close the
  gap between what we know and what we dobetween
  knowledge and practice.
• What we know
• Consumer preference
• Cost-effectiveness of HCBS
• Growing need for LTC
• What we do
• NH dominance

3
Creating a Balanced System (contd)

• Strategies to close the gap
• Consolidating administrative responsibility for
  all LTC financing and service delivery (OR and
  WA)global budgets
• Implementing managed care strategies designed to
  administer all services and funding sources under
  a capitated rate structure.

4
Creating a Balanced System (contd)

• Managed care strategies
• Several states have implemented some form of
  managed LTC (MLTC), but only one (AZ) has a
  statewide MLTC system
• Nationally, only 3 of all publicly funded LTC
  consumers are in MLTC.
• This percentage may increase rapidly with the
  introduction of special needs programs (SNPs),
  which are part of the MMA and the growing
  interest of some managed care organizations in
  LTC.

5
Brief Overview of MLTC Programs

• LTC Capitation
• Arizona (ALTCS
• Texas (Star Plus)
• New York
• Wisconsin (Family Care
• Florida (Diversion, Senior Care)
• Medicare and Medicaid capitation
• PACE, Wisconsin Partnership, Minnesota (MSHO),
  Massachusetts (Senior Care Options)

6
Managed LTC Programs

• These programs represent a range of managed LTC
  models involving not-for-profit and for-profit
  organizations or combinations of both.
• Four combine Medicaid and Medicare (PACE, MSHO,
  WPP, MSCO).

7
Wisconsin Family Care Program A Potential Model
for Aging Network-Based Managed Long-Term Care

• The Wisconsin Family Care Program appears to be
  the most aging-network-anchored MLTC program
• Operating in five counties, Family Care has two
  major componentsaging and disability resource
  centers and care management organization, both of
  which are run by the counties.
• Aging resource centers
• Care management organizations
• Funding sources, capitation (shared risk and no
  reimbursement)
• Consumer-focused seamless system
• Waiting lists

8
Wisconsin Family Care Analysis of Costs

• Total Medicaid costs.
• Less for Family Care members in the non-Milwaukee
  CMOs and for the frail elders served by the
  Milwaukee CMO than for their matched comparison
  groups.
• Sources of savings
• - Family Care reduces costs directly by
  purchasing or providing services more
  economically, and
• - Family Care reduces costs indirectly by
  favorably affecting Family Care members health
  status and functional abilities so that they have
  less need for services.

9
Wisconsin Family Care (contd)

• Long-term care costs.
• Average individual monthly LTC costs for Family
  Care members outside Milwaukee were lower than
  those of the matched comparison group, both at
  baseline (250 less) and at the end of the study
  period (722 less).
• For the frail elders served in Milwaukee, average
  individual monthly LTC costs were 1 less than
  those for the comparison group at the baseline,
  and 565 less at the end of the study period.

10
Wisconsin Family Care (contd)

• Sources of the Family Care savings.
• Average individual monthly costs at the end of
  the study period for the Milwaukee County frail
  elders care in community-based residential
  facilities (CBRFs) was 462 more than that spent
  for CBRF care for the comparison group.
• On the other hand, average individual monthly
  costs for nursing facility care of frail elders
  served by the Milwaukee CMO were 1,363 less than
  those for frail elders in the matched comparison
  group at the end of the study period.
• This is a direct result of the flexibility in
  funding provided by the Family Care benefit
  package.

11
Wisconsin Family Care (contd)

• Estimating potential future savings.
• The estimated monthly savings for the current
  enrollment levels (9,396) is roughly 1.9 million
• This implies that for every 1,000 persons
  enrolled in an expanded Family Care program, an
  additional 452,000 Medicaid dollars would be
  saved on a monthly basis.

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Summary Observations

• Perhaps the most fundamental message conveyed by
  this overview is that the traditional aging
  network organizations who administer the HCB
  Medicaid waiver services have the demonstrated
  capacity to provide an array of community-based
  LTC services efficiently, in either a FSS or
  managed care arrangement.
• This does not mean, however, that aging network
  organizations can assume that the future of
  community-based LTC will be a replication of the
  past.

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Summary Observations (contd)

• In many states, they are likely to be challenged
  by MCOs, which are increasingly prepared to
  administer LTC through integrated plans, which
  may receive a boost from the SNP initiative in
  the MMA.
• Aging network providers response should
  seriously consider the development of their own
  managed LTC programs designed to achieve greater
  efficiencies in the use of resources
• Improve the fit between consumer preferences and
  services provided (closing the gap).

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Summary Observations (contd)

• At a minimum, policymakers, taxpayers, and LTC
  consumers are likely to benefit from a diversity
  of strategies to provide LTC more efficiently
  over the next several years
• Includes managed LTC systems and the current
  fee-for-service approach where managed care
  strategies are not feasible (e.g., some rural
  areas)

15
The Ethics of Long-Term Care

• Finally, we need to address the ethical dimension
  of LTC. I think it is important to preserve and
  strengthen a mission-driven, ethics-of-care focus
  in LTC. This focus has guided the work of the
  aging network for over 30 years.
• We need to avoid the complete commodification of
  formal caregiving services and relationships

16
Ethics (contd)

• There may be some states or regions within states
  where the AN will not be able to administer the
  entire public LTC system under capitated
  arrangements and proprietary managed care
  organizations may be better prepared to play this
  role. Or, it may be best to continue current FFS
  arrangements with AN providers.
• Where feasible, however, I think the AN should
  step forward and, based on the organizational
  capacities, social capital and moral resources
  accumulated over the last 30 years, exercise the
  leadership we will need to create a more
  responsive and cost-effective LTC system in the
  years ahead.

17
Ethics (contd)

• The resources of the AN are essential in meeting
  what the Presidents Council on Bioethics (Leon
  Kars, 2006) calls the potential crises of
  caregiving
• 1) the danger that some old people will be
  abandoned or impoverished, with no one to care
  for them, no advocate to stand with them, and
  inadequate resources to provide for themselves.
• 2) the complete transformation of caregiving
  into labor, creating a situation where peoples
  basic physical needs are efficiently provided for
  by workers, but their deeper human and
  spiritual needs are largely ignored.