Board of Directors
William H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Aging and the
Health Care System
Daniel Wolf
Martin L. Gross, Chair
Emeritus
Directors Emeritus
New Hampshire House
Long-Term-Care Commission
Sheila T. Francoeur
Stuart V. Smith, Jr.
Donna Sytek
March 18, 2014
Brian F. Walsh
Kimon S. Zachos
“…to raise new ideas and improve policy debates through quality
information and analysis on issues shaping New Hampshire’s future.”
1
Major Areas of
Consideration
•
•
•
•
•
Aging
Service Demand
Service Supply
Financing
Responsibility and
Authority for Policy
• Flexible Systems (Peak
Load)
Critical Questions
•
•
•
•
•
•
•
•
•
How will demand for different services change as a result of aging and new
disease burden (e.g. dementia)?
Is the system of supports for aging sufficient to meet this growing demand
(caretakers, institutions)?
Is a state solution the right answer? How do regional differences impact the
questions being asked?
Does the growth of Medicare enrollment and changes in Medicaid
(expansions to 55-64-year-old adults) provide opportunities?
What does a long-term-care accountable care organization look like?
How do these answers affect the state’s implementation of managed care for
long term care services?
How do national policy changes (Affordable Care Act) and potential
recommendations out of the long term care commission impact New
Hampshire?
What role will the counties play in providing the services needed across the
spectrum of long-term-care supports and services (Meals on Wheels to
institutional care)?
Long-term-care expenditures are projected to grow more quickly then
revenues. How will the state and counties finance these changes?
Are we old? Not yet, but
getting there …
Population Projections For those Over the Age of 65
500,000
450,000
400,000
350,000
~126,000
300,000
~120,000
250,000
437,194
200,000
383,087
311,144
150,000
245,952
100,000
191,403
50,000
0
2010
2015
2020
2025
2030
4
Geography Matters
5
The new 60? Significant
growth of 75-79 population
Change In Population over the Age of 65 2010-2030
90,000
78,415
80,000
70,000
60,000
61,173
58,646
50,000
40,000
34,277
30,000
20,000
13,280
10,000
0
65-69
70-74
75-79
Age
80-84
85+
6
7
The
Geography
of Elderly
Poverty
Predicting the Future in
Spending
Private Pay – Tremendous
growth in 45-64 y.o. range
Spending 2010 and Age Only Simulated 2030
$1,800,000,000.00
$1,678,406,996
$1,600,000,000.00
$1,400,000,000.00
$1,200,000,000.00
$1,033,472,506
$1,000,000,000.00
2010 All
2030 All
$800,000,000.00
$574,702,735
$523,595,054
$600,000,000.00
$400,000,000.00 $228,623,473
$84,023,769
$220,738,941
$200,000,000.00
$34,141,154
$0.00
0-19
20-44
45-64
65+
Aging has
real impacts on Medicare ….
Impact of Aging on Total Spending in Medicare
Estimated 2010 Spending and Aging Impacts on 2030 only
$3,000
Spending 2010
Spending 2030
$2,709
$2,409
$2,500
In Millions $
$2,000
$1,500
$956
$1,000
$881
$513
$500
$296
$144 $135
$0
19-64
65-74
75-84
85+
Currently, much of the Medicaid
spending is for those under the
age of 65 (2009)
Medicaid Spending 2009 by Age and Sex
$300,000,000
$250,000,000
$200,000,000
2010 (Women)
2010 (Men)
$150,000,000
$100,000,000
$50,000,000
$0
0-19
20-44
45-64
65-74
75 - 84
85 +
A very different picture
in 2030
2030 Aged 2009 Medicaid Spending by Age and Sex
$400,000,000
$350,000,000
2030 (Women)
2030 (Men)
$300,000,000
$250,000,000
$200,000,000
$150,000,000
$100,000,000
$50,000,000
$0
0-19
20-44
45-64
65-74
75 - 84
85 +
Shifts in Medicaid
Spending
2009 Medicaid Spending by Age
85 +
11%
75 - 84
8%
0-19
29%
2030 Aged (2010) Spending
0-19
19%
85 +
23%
65-74
6%
20-44
17%
45-64
22%
75 - 84
19%
20-44
24%
65-74
10%
45-64
12%
14
Driven by Age and Shifts in
Demand for Services
78 PRIV NON-MED
INST FOR CHILDREN
1%
2009
78 PRIV NON-MED
INST FOR CHILDREN
2%
66 HOME&COMM
BASED CARE-CI &
ELD
6%
65 HOME&COMM
BASED CARE - DI
16%
1 INPATIENT
HOSPITAL, GENERAL
6%
All Other
7%
7 OUTPATIENT
HOSPITAL, GENERAL
6%
11 SKILL NURSING
FAC NURSING HOME
1%
12 INTERMED CARE
FAC NURSE HOME
31%
45 DENTAL SERVICE
2%
43 PHYSICIANS
SERVICES
4%
15 SNF NURSING
HOME ATYPICAL
CARE
32 FURNISHED MED
0%
SUP OR DME
16 ICF NURSING
1%
HOME ATYPICAL
17 MENTAL HEALTH
30 DISPENSE
CARE
CENTER
PRESCRIBED DRUGS
0%
25 CLINIC SERVICES
8%
7%
3%
2030
1 INPATIENT
7 OUTPATIENT
HOSPITAL, GENERALHOSPITAL, GENERAL
All Other
4%
5%
6%
66 HOME&COMM
BASED CARE-CI &
ELD
8%
11 SKILL NURSING
FAC NURSING HOME
2%
65 HOME&COMM
BASED CARE - DI
13%
45 DENTAL SERVICE
1%
43 PHYSICIANS
SERVICES
3%
32 FURNISHED MED
SUP OR DME
1%
30 DISPENSE
PRESCRIBED DRUGS
5%
25 CLINIC SERVICES 17 MENTAL HEALTH
CENTER
2%
6%
12 INTERMED CARE
FAC NURSE HOME
42%
15 SNF NURSING
HOME ATYPICAL
CARE
0%
16 ICF NURSING
HOME ATYPICAL
CARE
1%
Nursing Home Care
15
Can the current system support
such demand for institutional and
non-institutional services?
16
Large Growth in Spending
The Impact of Aging Only
$7,000
$6,000
2010
2030
$5,766
$5,000
$4,000
$3,000
$2,507
$2,277
$1,871
$2,000
$1,496
$992
$1,000
$0
Medicaid
Private
Medicare
Medicare will play a
growing role in driving the
healthcare system
2030
Millions of $
2010
Millions of $
Medicaid, $992,
19%
Medicaid,
$1,496, 15%
Medicare,
$2,277, 45%
Private, $2,507,
26%
Private, $1,871,
36%
Medicare,
$5,766, 59%
Workforce Issues will
become more acute.
The Workforce Is Aging
As Well!
Distribution of Family Practitioners by Age (2004)
45%
40%
40%
Percetn of Total
35%
31%
30%
29%
New Hampshire
United States
31%
25%
20%
18%
13%
15%
15%
11%
10%
4% 5%
5%
1% 2%
0%
FP < 35
FP 35 - 44
FP 45 - 54
FP 55 - 64
Age Group
FP 65 to 74
FP 75 +
Capacity Questions
•
•
•
•
•
Home Health
Home and Community Based Care slots
Geriatric hospital services
Assisted Living Facilities
Alzheimer's Support (Hospital, Nursing
Homes)
• Prisons
• Inpatient versus Outpatient services
What does a
comprehensive
assessment of the system
of LTC supports look like?
Acute
Medical
Chronic
Medical
Community
Based LTC
Assisted
Living
Nursing
Home
What does a Long-Term-Care Accountable Care
Organization Look Like?
Support and Information
•
•
•
•
Service Link (ADRC)
Legal Services
211 Calls
Other ?
24
Financial Assistance
(2012)
• TANF Grants for Lower Income Elderly
– Household size of one must be under $712 per month
and aged 65 or older; Average grant is $164.13 in
July 2012
• Property Tax Exemptions?
– 96% of cities and towns provide mandated base
elderly exemption (94% provide additional value)
– In 2006, 11,753 individuals received an exemption,
average $1,727 for a total of $20.3 million across the
entire state.
• Local welfare expenditures?
25
Nutrition (2012)
• Food-stamps
– Maximum grant is about $5.80 per day per person.
Of a total 56,887 cases in July (2012), 5,944 or 5.1%
are over age 65. Of these, 1,215 have a cash grant
• Meals Programs (Title III)
– 11,454 individuals received home delivered meals.
– 17,192 received congregate meals
• Local food kitchens
26
Other
• Housing
– Section 8 housing?
– Other efforts
• Transportation
– Title III – provided almost 19 visits per person over
the age of 65 living in poverty in NH.
– Medicaid provides transportation services
• Acute Healthcare
– Medicaid
– Local Welfare
27
State (or county based)
Long Term Care Supports
• Public Health (support for falls, chronic
conditions for those 55 to 64)
• Medicaid Nursing Home
• Home and Community Based Care
• Title III
– Adult Day Care – 654 individuals received support
– Homemaker – 645 individuals received support
– Personal Care Services – 523 received support
28
What about the impact of
the budgetary changes
from 2010 – 2013?
A
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
21
22
23
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
BEAS
B
Department of Health and Human Services
Adjustments to BEAS Budget Requests
General Funds Rounded to $000
E
F
G
H
SFY10
SFY11
SFY12
SFY13
($808)
($8,438)
($839)
$0
($853)
($751)
($514)
($324)
($259)
($250)
($166)
($105)
($130)
($1,397)
($8,606)
($1,520)
($2,000)
($879)
($766)
($575)
($330)
($259)
($260)
($166)
($119)
($130)
Rate Reduction-Contracted Services
MQIP 100% (State Retains 25%)
Redefine/clarify Rule for Personal Care Services & Homemaker Services
Raise county cap by 2% in line with inflation
Require Single Dose Medication for H.H.RN Visits
Freeze funding Congregrate Housing Supports
Discontinue Case Management to Mid-Level Care
Freeze funding ADRD & Caregiver Program
Funding from Money Follows The Person
Eliminate Catastrophic Illness Program
Reduce general funds for SSBG programs
Freeze State Funding of Service Link Program
Volunteer -Sr. Companion-Foster Grandparent
HCBC-ECI - Rebalancing Similar Services
Adjust county cap for nursing services
Reduced class 512 transportation of clients
($1,303)
($2,253)
($12)
($400)
$0
($134)
($184)
($400)
($500)
($134)
The National Long Term
Care Commission
• The Commission identified the following problems with the
current LTSS system:
• Currently, family caregivers are providing most of the
care, but their responsibilities can be very overwhelming.
Their availability will decline as more of the population
ages.
• Many Americans approaching retirement are unaware of
how costly paid LTSS are and are not prepared for these
expenses.
• There are training and retention problems within the direct
care workforce that will affect the quality and accessibility
of practiced employees in the future.
• Paid LTSS are fragmented and difficult to access. They
often lack the focus and efficiency that would result in the
best outcomes, all the while remaining a financial burden.
Critical Questions
•
•
•
•
•
•
•
•
•
How will demand for different services change as a result of aging and new
disease burden (e.g. dementia)?
Is the system of supports for aging sufficient to meet this growing demand
(caretakers, institutions)?
Is a state solution the right answer? How do regional differences impact the
questions being asked?
Does the growth of Medicare enrollment and changes in Medicaid
(expansions to 55-64-year-old adults) provide opportunities?
What does a long-term-care accountable care organization look like?
How do these answers affect the state’s implementation of managed care for
long term care services?
How do national policy changes (Affordable Care Act) and potential
recommendations out of the long term care commission impact New
Hampshire?
What role will the counties play in providing the services needed across the
spectrum of long-term-care supports and services (Meals on Wheels to
institutional care)?
Long-term-care expenditures are projected to grow more quickly then
revenues. How will the state and counties finance these changes?
New Hampshire Center
for Public Policy Studies
Board of Directors
William H. Dunlap, Chair
David Alukonis
Eric Herr
Dianne Mercier
James Putnam
Todd I. Selig
Michael Whitney
Daniel Wolf
Martin L. Gross, Chair
Emeritus
Directors Emeritus
Sheila T. Francoeur
Stuart V. Smith, Jr.
Want to learn more?
• Online: nhpolicy.org
• Facebook: facebook.com/nhpolicy
• Twitter: @nhpublicpolicy
• Our blog: policyblognh.org
• (603) 226-2500
Donna Sytek
Brian F. Walsh
Kimon S. Zachos
“…to raise new ideas and improve policy debates through quality
information and analysis on issues shaping New Hampshire’s future.”