the aging population: a medi-cal perspective...october 2016 dhcs - research and analytic studies...
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The Aging Population:A Medi-Cal Perspective
October 2016
Created by the DHCS –Research and Analytic Studies Division
October 2016 DHCS - Research and Analytic Studies Division
Medi-Cal is a public health insurance program that provides free or low-cost health coverage for children and adults with limited income and resources.
+
October 2016 DHCS - Research and Analytic Studies Division
Medi-Cal is a State & Federal partnership.
2
Medi-Cal covers: • low-income adults;• families with children;• seniors;• persons with disabilities;• children in foster care, as well as
former foster youth up to age 26;• pregnant women; and• individuals with special health
needs.
October 2016 DHCS - Research and Analytic Studies Division 3
How Many Californians Are Enrolled in Medi-Cal?
-10%
-5%
0%
5%
10%
15%
20%
25%
30%
35%
40%
-
2,000,000
4,000,000
6,000,000
8,000,000
10,000,000
12,000,000
14,000,000
16,000,000
% of California Population in Medi-Cal Year-over-Year % change Average Monthly Eligibles
Over 13.5 million beneficiaries
Medi-Cal covers 34% of all Californians
Medi-Cal Covers Half ofCalifornia Resident Births
23.4% 22.4%
36.1%
41.3% 42.4%46.0%
49.2%
50.7%
49.8%
0%
10%
20%
30%
40%
50%
60%
% o
f Cal
iforn
ia B
irths
4October 2016 DHCS - Research and Analytic Studies Division
Medi-Cal has covered more than 40% of California resident hospital births since 1992, and Medi-Cal proportions have increased even as total number of births has decreased.
In 2010, the proportion of births financed by Medi-Cal in California was 50.7%. In 2013, it was slightly lower at 49.8%.
5
Medi-Cal Covers More than Halfof California’s Children
October 2016 DHCS - Research and Analytic Studies Division
Medi-Cal covers roughly six out of 10 children in the state. In some counties, Medi-Cal is the primary source of health care coverage for 80% of all children.
58%
36%27% 22% 23%
34%
42%
64%73% 78% 77%
66%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Age 0 to 17 Age 18 to24
Age 25 to44
Age 45 to64
Age 65 orolder
All Ages
With Medi-Cal Without Medi-Cal
Perc
ent o
f Sta
tew
ide
Popu
latio
n
October 2016 DHCS - Research and Analytic Studies Division 6
Proportion of Californians Enrolled in Medi-Cal, By County (FFY 2013-14)
Medi-Cal is the primary health care coverage for many geographic regions of the state.
In some counties within the Central Valley, Medi-Cal provides coverage to more than 50% of the population.
7
Medi-Cal’s Role in FinancingLong-Term Care Services
October 2016 DHCS - Research and Analytic Studies
Percent of LTC Nursing Facility
Residents Relying on
Medi-Cal For Payment
65%
Percent of LTC Nursing Facility Residents Not
Relying on Medi-Cal
35%
Division
Among California's long-term care (LTC) residents, nearly two-thirds rely on Medi-Cal to finance their care.
Roughly 100% of individuals who reside in homes for the developmentally disabled rely on Medi-Cal to pay for their care.
Source: California Association of Health Facilities http://www.cahf.org/AboutCAHF/ConsumerHelp/GuidetoLongTermCare.aspx
October 2016 DHCS - Research and Analytic Studies Division 8
State Financing of Medi-Cal
October 2016 DHCS - Research and Analytic Studies Division 9
In The Headlines – Medicaid’s Financial Burden
October 2016 DHCS - Research and Analytic Studies Division 10
Medi-Cal's Funding Mix: How Has It Changed?
$21.8 $23.4 $24.3
$31.1 $28.8
$36.0
$42.7
$58.6 $58.9 $57.8
$14.3 $14.4 $15.4 $13.6 $14.7 $14.4 $16.1 $17.3 $18.0 $17.8
$0.9 $0.8 $0.9 $5.5
$2.1 $8.9 $10.8 $13.5 $14.1 $14.8
$37.0 $38.5
$40.5 $50.2 $45.5
$59.3
$69.5
$89.4 $91.0 $90.3
$0
$10
$20
$30
$40
$50
$60
$70
$80
$90
$100
2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17
Federal State General Fund Other Total
Federal funding sees sharp increase as ACA is implemented
$ in
Bill
ions
Federal funding has taken a larger role in financing Medicaid programs throughout the nation, and California is no exception.
The adoption of the Affordable Care Act (ACA), provider taxes, quality assurance fees, certified public expenditures, and other means have brought in additional federal funds that have allowed Medi-Cal to enhance the program and offer coverage to new populations.
Medi-Cal’s new adult population, which began enrollment in CY 2014, is financed entirely by the federal government for the first three years, phasing down to 90% in 2020.
State general fund spending has grown modestly over the past nine years.
October 2016 DHCS - Research and Analytic Studies Division 11
Source: Medi-Cal Appropriation Estimate SFY 2016-17, http://www.dhcs.ca.gov/dataandstats/reports/mcestimates/Documents/2016_May_Estimate/M1601_Approp_Funding_Sum.pdf
Medi-Cal Budgeted SpendingBy Funding Source (SFYs 2007-08 Through 2016-17)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
59% 61% 60% 62% 63% 61% 61% 66% 65% 64%
39% 37% 38% 27%32%
24% 23% 19% 20% 20%
2% 2% 2%
11% 5%15% 15% 15% 15% 16%
2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-1
Federal State General Fund Other
7
Budgeted federal funds financed 64% of Medi-Cal spending in SFY 2016-17, while state-budgeted general funds financed 20%, and other funds accounted for 16%.
The major shift in funding proportions has been primarily driven by the absorption of the Healthy Families Program into Medi-Cal in 2013 (representing a 65-35 split between federal and state dollars, respectively); implementation of the ACA in January 2014; and the use of other funds (e.g. provider taxes, quality assurance fees, CPEs, etc.).
October 2016 DHCS - Research and Analytic Studies Division 12
Medi-Cal Spending as a Percentage of California's Overall Budgeted General Fund Spending (SFY 2016-17)
K-12 Education42%
Higher Education
12%
Corrections and
Rehabilitation9%
Natural Resources
2%
Other8%
Medi-Cal14.5%
Other HHS12.5%
Health and Human Services
27%
Medi-Cal spending accounts for roughly 14% of the state’s general fund spending.
This is in line with U.S. averages that indicate that Medicaid represents roughly 14% to 18% of state general fund budgets.
State general funds consist of expenditures from revenues raised through income, sales, and other broad-based state taxes.
Sources: Medi-Cal Appropriation Estimate SFY 2016-17, Department of Finance – California’s Enacted Budget SFY 2016-17http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html
Total = $122.6 billion
October 2016 DHCS - Research and Analytic Studies Division 13
Medi-Cal Budgeted Spending as aPercentage of State General Fund (SFYs 2007-08 Through 2016-17)
14.0%13.9%
18.2%
15.7%17.1%
15.1%
16.7% 16.0% 15.6%14.5%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
20%
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
2015-16
2016-17
% o
f Sta
te B
udge
ted
GF
Spen
ding
Sources: California Summary Charts, Figure – Sum – 03 for select years. http://www.ebudget.ca.gov/Medi-Cal Appropriation Estimates for select years.
Medi-Cal spending as a percent of state-budgeted general fund spending has remained relatively stable over the past 10 years.
Medi-Cal has accounted for between 13.9% and 18.2% of budgeted general fund spending.
October 2016 DHCS - Research and Analytic Studies Division 14
Medi-Cal Spending as a Percentage of California's Overall Budgeted Spending (SFY 2016-17)
Budgeted Spending Not
Medi-Cal$308.6 billion
(77%)
Medi-Cal Budgeted Spending
$90.3 billion(23%)
Total = $398.9 billion
Source: Medi-Cal Appropriation Estimate SFY 2016-17, Department of Finance – California’s Enacted Budget Sfy 2016-17http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html
Because Medi-Cal brings in substantial federal funds, another way to look at Medi-Cal in the context of state spending is to evaluate all state spending.
Medi-Cal spending accounts for roughly 23% of California’s overall state spending. Nationally, Medicaid accounts for 25% of overall state spending.
Overall state-budgeted spending includes federal, state, and all other funds combined.
Medi-Cal Is Heavily Dependent on Federal Funding
• Medi-Cal covers 34% of all Californians,
including 58% of the state’s children, and
50% of all resident births.
• Federal contributions have increased
sharply, and now account for 65% of Medi-
Cal’s budget.
• Changes in federal policy in response to
budgetary pressures or economic downturns
may introduce complex and difficult funding
decisions in the future.
October 2016 DHCS - Research and Analytic Studies Division 15
October 2016 DHCS - Research and Analytic Studies Division 16
Federal Financing of Medi-Cal
October 2016 DHCS - Research and Analytic Studies Division
Source: Congressional Budget Office, An Update to the Budget and Economic Outlook: 2016 to 2026 https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf
17
CBO Baseline Budget Projections2016 Through 2026
-
1,000
2,000
3,000
4,000
5,000
6,000
7,000
2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026
Spen
ding
In
Billi
ons
Revenues Spending
Spending
Revenues DEFICIT
Federal spending is projected to exceed revenue from 2016 through 2026.
The Congressional Budget Office (CBO) predicts that spending for mandatory programs will rise nearly 70% in nominal terms from 2016 to 2026.
They attribute most of this increase to the aging of the population and rising health care costs per person.
October 2016 DHCS - Research and Analytic Studies Division 18
What Is Driving Federal Deficits?
Major Health Programs
34%
Social Security29%
Net Interest19%
All Other Programs
18%
82% ofgrowth in spending isdriven by three categories
Source: Congressional Budget Office, An Update to the Budget and Economic Outlook: 2016 to 2026 https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf
Federal spending is projected to grow substantially between 2016 and 2026.
The CBO estimates that 82% of the growth in federal spending will come from three major components: net interest; Social Security; and major health programs.
The major health programs include Medicare, Medicaid, Children’s Health Insurance Programs, and health care subsidies for the ACA.
October 2016 DHCS - Research and Analytic Studies Division 19
2015 Actual Federal Expenditures
Source: Congressional Budget Office, An Update to the Budget and Economic Outlook: 2016 to 2026 https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf
Mandatory spending accounts for 62% of all federal spending. When interest on the debt is added in, mandatory plus interest accounts for 68% of all federal spending.
Social Security, Medicare, Medicaid, and other health account for 50% of all federal spending.
By 2026, the Congressional Budget Office estimates that mandatory spending plus interest on the debt will account for 77% of all federal spending.
Mandatory SpendingDiscretionary Spending
32% 62%
Interest 6%
Social SecurityNon-Defense24%16%
Defense Medicare16% 17%
Other Health and Income Sec.
MedicaidPrograms9%12%
October 2016 DHCS - Research and Analytic Studies Division 20
Federal Debt Held By the Public Federal debt held by the public is projected to rise from 77% of GDP in 2016 to 86% in 2026.
According to the CBO, when the debt as a percentage of GDP reaches 86%, it would be more than twice the average over the past 50 years.
The CBO predicts, assuming no changes in laws, that three decades from now the debt held by the public will be about twice as high relative to GDP. This would be higher than the U.S. has ever experienced.
0
20
40
60
80
100
12019
40
1945
1950
1955
1960
1965
1970
1975
1980
1985
1990
1995
2000
2005
2010
2015
2020
2025
% o
f GDP
2016: Actual U.S. debt approximately $14 trillion (77% of GDP)
2026: Projected U.S. debt at $23 trillion (86% of GDP)
Deficits & Debt May Necessitate Reforms• The Medi-Cal program is highly dependent
on federal funding.
• Policy changes at the federal level may
greatly impact Medi-Cal in the future.
• Policymakers will have to consider a
combination of tax, spending, and
entitlement reforms.
• Federal and state governments, as well as
Medicaid stakeholders, are going to have
to work together and find more cost-
effective ways to deliver health care.
October 2016 DHCS - Research and Analytic Studies Division 21
October 2016 DHCS - Research and Analytic Studies Division 22
Actual Spending and Demographics:
Medi-Cal in FFY 2013-14
October 2016 DHCS - Research and Analytic Studies 23Division
Total Medi-Cal BeneficiariesN=12,952,327
$=87,910,546,884
The Medi-Cal Population in FFY 2013-14
Aged
n = 1,135,824 (9%)
$ = 30,891,905,156 (35%)
Medi-Cal$ = 13,697,792,859
(44%)
Medicare$ = 17,194,112,297
(56%)
Blind/Disabled
n = 1,247,546 (10%)
$ = 31,068,261,428 (35%)
Medi-Cal$ = 23,107,732,950
(74%)
Medicare$ = 7,960,528,479
(26%)
Low-Income
n = 10,568, 957 (82%)
$ = 25,950,380,299 (30%)
Medi-Cal $ = 25,300,972,398
(97%)
Medicare$ = 649,407,901
(3%)
October 2016 DHCS - Research and Analytic Studies Division 24
More Females in the AgedEligibility Group
The Aged eligibility group included a much larger proportion of females (62%) vs. males (38%) compared to the other eligibility groups. This disparity is primarily driven by differences in life spans.
The Low-Income group also included a larger proportion of females compared to males, due to the fact that Historically, Low-Income eligibility pathways focus on women of child-bearing age, though this has changed.
38%53%
46%
62%47%
54%
Aged (n=1,135,824) Disabled (n=1,247,546) Low-Income(n=10,568,957)
Distribution of Medi-Cal Population inFFY 2013-14, by Gender
Male Female
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
October 2016 DHCS - Research and Analytic Studies Division 25
Sixteen Percent of Aged Eligibility Group is Ages 85 and Older
26%
52%
74%
48%
84%
16%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aged (n=1,135,824) Disabled (n=1,247,546) Low-Income(n=10,568,957)
FFY 2013-14, by Age Group
Ages 0-19 Ages 20-64 Ages 65-84 Ages 85 and Older
Distribution of Medi-Cal Population in
The Aged eligibility group was predominately comprised of individuals ages 65-84 (84%), with 16% being ages 85 and older. The Disabled group included a much larger proportion of eligibles ages 20-64 (74%) compared to the Low-Income group (48%).
October 2016 DHCS - Research and Analytic Studies Division 26
Aged and Disabled More Likelyto Be Dually Eligible
88%
31%
0.4
12%
69%
99.6%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aged (n=1,135,824) Disabled (n=1,247,546) Low-Income(n=10,568,957)
Distribution of Medi-Cal Population inFFY 2013-14, by Dual Status
Dual Eligible Non-Dual Eligible
%
Dual Eligiblescomprised a majority of the Aged eligibility group (88%), while the Low-Income group was comprised almost entirely of non-Dual Eligible individuals.
Close to one-third of the Disabled eligibility group was dually eligible, and many were within the two-year disability waiting period.
October 2016 DHCS - Research and Analytic Studies Division 27
Race/Ethnicity Vary by Eligibility Group
29.1% 27.1%
52.8%
24.0% 30.7%
18.4%17.0%20.1%
10.5%24.2% 6.9%
10.4%
5.4%14.5%
7.6%
0.3% 0.7% 0.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Aged Disabled Low-Income
Distribution of Medi-Cal Population inFFY 2013-14, by Race/Ethnicity
NativeAmerican
African-American
Asian
Missing /NotReported
Non-HispanicCaucasian
Hispanic
All Medi-Cal eligibility groups are ethnically/racially diverse. Hispanics and Non-Hispanic Caucasians represent the largest proportion of eligibles overall, and Native American eligibles represent the smallest proportion.
The demographic characteristics of elderly Medi-Cal beneficiaries are different from those of other Medi-Cal groups. For example, elderly Medi-Cal beneficiaries in the Aged eligibility grou p are 3.5 times more likely to be of an Asian race/ethnicity compared to the Disabled group, and 2.3 times more likely to be Asian compared to the Low-Income group.
October 2016 DHCS - Research and Analytic Studies Division 28
Aged, Disabled Eligibility Groups Generate Disproportionate Spending
Medi-Cal spending is not equally distributed relative to population shares.
Medi-Cal's Low-Income population constituted 82% of the overall population, but accounted for only 30% of total spending.
In contrast, Medi-Cal's Aged population represented 9% of the overall population, but accounted for 35% of total spending.
Similarly, Medi-Cal's Disabled population constituted 10% of the overall Medi-Cal population and accounted for 35% of overall spending.
9%
35%10%
35%82%
30%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Unduplicated Eligibles(12,952,327)
Total Spending($87,910,546,884)
Medi-Cal Spending By Eligibility GroupFFY 2013-14 Dates-of-Service
Aged Disabled Low-Income
Source: Medi-Cal and Medicare Eligibility data
October 2016 DHCS - Research and Analytic Studies Division 29
Age and Health Care Spending –Aggregate Medi-Cal and Medicare Expenditures (FFY 2013-14)
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
$-
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
0 20 40 60 80
Elig
ible
s
Aggr
egat
e Sp
endi
ng (i
n m
illio
ns)
Age
Medi-Cal Spending Medicare Spending Eligibles
A substantial amount of overall Medi-Cal spending is generated by children and young adults, reflecting their greater numbers in the program. Medi-Cal spending rises sharply between ages 40 and 64, reflecting increasing numbers of disabled individuals in that age range. At age 65 Medi-Cal costs fall, reflecting the transition of responsibility for most coverage to Medicare. However, Medi-Cal’s costs do not fall completely, as Medi-Cal is still responsible for providing Long-Term Services and Supports (LTSS).
October 2016 DHCS - Research and Analytic Studies Division 30
Age and Health Care Spending –PMPM Spending
-
50,000
100,000
150,000
200,000
250,000
300,000
350,000
$-
$1,000.00
$2,000.00
$3,000.00
$4,000.00
$5,000.00
$6,000.00
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 9510
0+
Elig
ible
s
Per M
embe
r Per
Mon
th S
pend
ing
Age
Medi-Cal PMPM Spending Medicare PMPM Spending
Eligibles
As displayed, “per member per month” (PMPM) spending is low in childhood and increase somewhat during young adulthood, reflecting the increased frequency of pregnancy and delivery.
Spending increases more after age 40, reflecting the increased frequency of disability and chronic disease. Medi-Cal PMPM spending declines somewhat after age 65, but begins steeply rising again at age 75 as the need for LTSS increases.
October 2016 DHCS - Research and Analytic Studies Division 31
How Do PMPM Costs Vary by Eligibility Group?
$1,389
$566$7
$1,106
$1,642
$256$0
$500
$1,000
$1,500
$2,000
$2,500
$3,000
Aged Disabled Low-Income
Comparison of PMPM Spending in FFY 2013-14,by Eligibility Group
Medicare Medi-Cal
(Total = $2,495)
(Total = $2,208)
(Total = $263)
The Aged and Disabled eligibility groups generated the highest combined Medi-Cal/Medicare PMPM spending, illustrating the complex conditions associated with these eligibles.
October 2016 DHCS - Research and Analytic Studies Division 32
Medi-Cal’s Aged Population
October 2016 DHCS - Research and Analytic Studies Division 33
Projected Growth of the California Population Ages 65 and Older
0
2
4
6
8
10
12
14
2010
2012
2014
2016
2018
2020
2022
2024
2026
2028
2030
2032
2034
2036
2038
2040
2042
2044
2046
2048
2050
2052
2054
2056
2058
2060
Calif
orni
a Po
pula
tion
65 y
ears
of a
ge a
nd o
lder
(in
mill
ions
)
Aged 65-74 years Aged 75-84 years Aged 85 years or older
2029: +97% since 2010 (8,415,973)
2060: +185% since 2010 (12,211,957)
2010:4,281,051
The California Department of Finance estimated that there are 5.4 million Californians ages 65 and older in 2016. The number increases to 6.2 million by 2020, 8.6 million by 2030, 10.1 million by 2040, and 11.2 million by 2050.
While the number of individuals ages 65 to 74 increases at a lower rate after 2030, the 75-84, and 85+ cohorts will continue to grow at a steeper rate through 2060.
October 2016 DHCS - Research and Analytic Studies Division
Source: Medi-Cal and Medicare Eligibility data
34
Eligibility Pathways for Medi-Cal’sAged Population
Aged-FPL18%
Aged-MN16%
Aged-PA3%
Blind/Disabled1%
LTC5%
Other<1%
Parent/Caretaker Relative
2%
SSI/SSP53%
Undocumented2%
N = 1,135,824
Medi-Cal provides low-income seniors with vital health care coverage.
Fifty-three percent (53%) of the Aged population are categorically eligible because they receive Supplemental Security Income/State Supplemental Payments (SSI/SSP).
Another 18% are eligible because they are enrolled through the Aged Federal Poverty Level program. Sixteen percent (16%) are eligible because they qualify under one of Medi-Cal’s medically needy programs. Five percent (5%) qualify because they require LTC services and are unable pay for it. Three percent (3%) qualify through public assistance; 2% qualify as parent/caretaker relatives; 1% qualify due to disability status but do not qualify for SSI/SSP; and a small group qualifies under one of the program’s other categories.
October 2016 DHCS - Research and Analytic Studies Division 35
Gender Distribution Changes with Age California’s aging population consists of more females than males, and this disparity increases with age.
More than any other socioeconomic group, women are disproportionately affected by LTC.
The reason behind this lies in the fact that women live longer than men, on average, and are more likely to develop the functional ailments that require LTC services. Two-thirds of residents in LTC facilities are women.
45% 41% 40% 38% 37% 33% 29%22%
55% 59% 60% 62% 63% 67% 71%78%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Ages 60to 64
Ages 65to 69
Ages 70to 74
Ages 75to 79
Ages 80to 84
Ages 85to 89
Ages 90to 94
Ages 95+
Gender Distribution By Age Group
Male Female
DivisionOctober 2016 DHCS - Research and Analytic Studies 36
The Aged Eligibility Group in FFY 2013-14Aged Eligibility Group
N = 1,135,824$ = 30,891,905,156
SpendingMedi-Cal = $13,697,792,859 (44%)Medicare = $17,194,112,297 (56%)
LTSS
Communityn = 314,733 (28%)
$ = 12,182,494,810 (39%)
Institutionaln = 108,646 (9%)
$ = 10,189,390,555 (33%)
No LTSSn = 712,445 (63%)
$ = 8,520,019,791 (28%)
MD
Eligibilityedi-Cal Only = 141,767 (12%)ual Eligible = 994,057 (88%)
October 2016 DHCS - Research and Analytic Studies Division 37
Concentration of Health Care Spending Withinthe Aged Eligibility Group
Least Costly 50%
Most Costly 20%
0
10
20
30
40
50
60
70
80
90
100
Cum
ulat
ive
Perc
ent o
f Tot
al S
pend
ing
Percent of Medi-Cal Population Ordered by Health Care Spending
The most costly one percent of the Aged population generated 11.4% of combined spending and had a PMPM cost of $26,962.
The most costly five percent of the Aged population generated 29.7% of combined spending and had a PMPM cost of $15,055.
The least costly fifty percent of the Aged population generated only 10.6% of combined spending and had a PMPM cost of $547.
Most Costly 1
Most Costly 5%
Most Costly 10%
%
October 2016 DHCS - Research and Analytic Studies Division 38
Combined Spending for Medi-Cal’sAged Eligibility Group, By Service Category (FFS); FFY 2013-14
As displayed, spending for inpatient hospital services account for 32% of all spending.
Payments for skilled nursing account for another 22% of spending, pharmacy accounted for 12%, and in-home supportive services account for 10%.
Inpatient Hospital
$4.44 32%
Skilled Nursing
$3.05 22%
Pharmacy$1.73 12%
Supportive Services
$1.33 10%
Physician and Clinical
$1.48 11%
Outpatient Hospital
$0.82 6%
Other$0.52 4%
Home Health$0.40 3%
Developmental Disability
Services$0.07 0%
Short-Doyle Mental Health$0.04 0%FFY 2013-14
In-Home
October 2016 DHCS - Research and Analytic Studies Division 39
Aged, Disabled Eligibility GroupsGenerate Disproportionate Acute-Care Inpatient Hospital Days
Source: Medicare and Medi-Cal Claims and OSHPD Patient Discharge data
9%
33%10%
35%82%
31%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Eligibles(N=12,952,327)
Total Inpatient Days
Inpatient Acute Hospital Days By Eligibility GroupFFY 2013-14 Dates-of-Service
Low-Income
Disabled
Aged
The distribution of acute-care inpatient hospital days generated by each of the three eligibility groups closely mirrors the distribution of overall spending. This is not surprising, since inpatient hospital care is a major driver of spending.
Medi-Cal's Low-Inc omeEligibility gro upconstituted 82% of the overall population, but accounted for only 31% of hospital days. In contrast, Medi-Cal's Aged eligibility group, representing only 9% of the overall population, accounted for 33% of hospital days.
October 2016 DHCS - Research and Analytic Studies Division 40
Acute-Care Inpatient Hospital Daysper 1,000 Member Months
176
165
21
52
- 50 100 150 200
Aged
Disabled
Low Income Beneficiary
Overall
Acute IP Days / 1,000 Member Months
Days / 1000 MM By Eligiblity Group
173
890
73
176
- 200 400 600 800 1,000
LTSS-Community
LTSS-Institutional
No LTSS
Overall
Acute IP Days / 1,000 Member Months
Aged - LTSS Status
Acute-care inpatient hospital use is highes tamong Medi-Cal’s Aged eligibility group.
The Aged eligibility group generated an acute-care inpatient hospital days per 1,000 member months rate that was 3.3 times greater than Medi-Cal’s rate overall, and more than 8 times greater than the rate seen in Medi-Cal’s Low-Income eligibility group.
Aged individuals residing in LTC facilities had the highest rate (890 days/1,000 member months).
October 2016 DHCS - Research and Analytic Studies Division 41
74.3%58.7%
45.2%42.6%42.3%
38.3%29.2%
26.5%24.3%
22.6%21.1%
19.3%18.8%18.3%
16.4%16.3%
15.5%13.8%
12.3%12.1%
9.9%9.1%9.0%
8.0%7.8%
0.0% 20.0% 40.0% 60.0% 80.0%
HypertensionHyperlipidemia
DiabetesRheumatoid Arthritis
AnemiaIschemic Heart Disease
CataractChronic Kidney Disease
Heart FailureDepression
Alzheimer's Related…Depressive Disorder
COPDPeripheral Vascular…
HypothyroidOsteoporosis
GlaucomaAnxietyObesity
Benign ProstateAsthma
Alzheimer's DiseaseAtrial FibrillationHearing Impaired
Stroke / TIA
Most Frequently Diagnosed Clinical Conditions Among the Aged Eligibility Group
Source: FFS Medicare and Medi-Cal claims and encounter data for calendar years 2013 and 2014.
Among the Aged eligibility group, the most frequently diagnosed clinical conditions include hypertension (74.3%), hyperlipidemia (58.7%), and diabetes (45.2%).
Alzheimer’s and other related disorders were also prevalent among the population (21%).
October 2016 DHCS - Research and Analytic Studies Division 42
Most Costly Clinical Subpopulations In terms of combined Medicare and Medi-Cal PMPM spending, the most costly clinical subpopulations among the Aged eligibility group included acute myocardial infarction ($9,750), hip fracture ($9,145), and pressure ulcers ($9,106).
$9,750 $9,145 $9,106
$8,810 $8,483
$8,269 $8,187
$8,010 $7,805 $7,705 $7,644 $7,534 $7,517
$7,344 $7,178 $7,045 $7,026
$6,710 $6,420 $6,280 $6,229 $6,206
$6,033 $5,995 $5,876
$- $2,000 $4,000 $6,000 $8,000 $10,000 $12,000
Acute Myocardial InfarctionHip Fracture
Pressure UlcersSpinal Cord Injury
Traumatic Brain InjuryEpilepsy
Mobility ImpairmentsIntellectual Disbilities
Other Developmental DisordersMuscular Dystrophy
Schizophrenia and Other PsychosisMultiple Sclerosis
Lung CancerBipolar Disorder
SchizophreniaStroke or TIA
BlindHIV AIDS
Hepatitis C -UnspecifiedAtrial Fibrillation
LeukemiaAlzheimer's Disease
Peripheral Vascular DiseaseAlzheimer's Related Disorders
Hepatitis C -Acute
Source: FFS Medicare and Medi-Cal claims and encounter data for calendar years 2013 and 2014.
October 2016 DHCS - Research and Analytic Studies Division 43
Impact of Multiple Concurrent Clinical Conditions
Source: Medicare claims and encounter data for calendar years 2013 and 2014; CMS Chronic Condition Warehouse (CCW) algorithms utilized to create chronic conditions. PMPM spending represented combined Medi-Cal and Medicare.
$144 $552 $974 $2,197
$5,610
$12,136
$-
$2,000
$4,000
$6,000
$8,000
NoConditions
1 to 2Conditions
3 to 4Conditions
5 to 9Conditions
10 to 15Conditions
More than15
Conditions
No Conditions
8% 1 to 2 Conditions
8%
3 to 4 Conditions
14%
5 to 9 Conditions
40%
10 to 15 Conditions
24%
More than 15
Conditions6%
Combined Medicare-Medi-Cal PMPM Spending
$14,000
$12,000
$10,000
The CMS Chronic Condition Warehouse (CCW) algorithm identifies 60 different chronic and potentially disabling clinical conditions.
October 2016 DHCS - Research and Analytic Studies Division 44
Distribution of Spending for Aged Eligibility Group by LTSS Status
Combined health care spending among Medi-Cal's Aged population is concentrated among those who are institutionalized.
Individuals who were LTC institutional utilizers represented 10% of the Aged population, but accounted for 33% of total combined Medi-Cal and Medicare spending.
Aged individuals who did not use LTSS throughout FFY 2013-14 comprised 63% of the Aged population and accounted for only 28% of overall combined spending.
Members of the Aged population who utilized LTSS not classified as institutional accounted for 28% of the Aged population and generated 39% of overall combined spending.
28%39%
10%
33%
63%
28%
Unduplicated Users(1,135,824)
Total Spending($30,891,905,156)
Aged Spending by LTSS Status
LTSS-Community LTSS-Institutional No LTSS
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
October 2016 DHCS - Research and Analytic Studies
Source: Medi-Cal and Medicare Eligibility data
Division 45
Combined Per-Capita Spending forthe Aged Eligibility Group by LTSS Status
$19,194
$48,286
$3,384$12,060
$19,514
$45,499
$8,575
$15,138
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
$90,000
$100,000
LTSS-Com.($38,707)
LTSS-Instit.($93,785)
No LTSS($11,959)
Overall($27,198)
Spen
ding
Per
Cap
ita
Total Medicare Spending Per Capita Total Medi-Cal Spending Per Capita
Health care spending per-capita varied significantly based on whether the individuals needed LTSS.
Individuals who utilized institutional LTSS had the highest per-capita cost ($93,785). Individuals who utilized LTSS not classified as institutional generated per-capita costs of $38,707. Aged individuals who utilized no LTSS generated a per-capita cost of $11,959.
Differences in per-capita costs were the result of a number of factors, including age and health conditions.
October 2016 DHCS - Research and Analytic Studies Division 46
Future of Health Care Faces PressuresMedicaid, like the nation’s entire health care system, will be challenged in the future. The aging population, budget deficits, and competition among limited resources will all require innovative and creative approaches to achieve sustainability.
The Future
Medicare is Not Free
(Cost-Sharing/
Copayment)
No National Financing
Plan for LTC
Retirement Preparation?
Federal Budget Deficits
State Budgets Must Be Balanced
Capacity of Health Care
Delivery System
Technology Impact
Demographic Trends – Aging
Population
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