WRAAA In Transition: Preparing

for the Future by Building on the Past

Ronald Hill, CEOWestern Reserve Area Agency on Aging

May 10, 2012

Context for Transitional Change

1. Agency’s 24 Year History and Evolution

2. Important Milestones in the Evolution of HCBS: 1980 - 2012

3. Major Factors Driving Change In WRAAA’s Operating Environment

4. Health Transformation in Ohio Under the Kasich Administration

5. Strategic Areas for AAAs and O4A and WRAAA Response

WRAAA History and Evolution

Three Transformational Periods:1988 - 1989

Incorporated as independent non-profit organization

Designated by State as AAA for 5-County Planning and Service Area (PSA 10A) comprising Cuyahoga, Geauga, Lake, Lorain, and medina Counties

1990 - 2012

Continued role as AAA for PSA 10A

Designated by State as PASSPORT Administrative Agency (PAA) for PSA 10A

2013 - 2016 (Future)

Continued role as AAA for PSA 10A

Role in ICDS for Duals?

Role in Medicaid HCBS Waiver?

Front Door Role as ADRN for ICDS and other HCBS?

Important Milestones in the Evolution of HCBS

1980 - 2012

1980: The Long-Term Care Channeling Demonstration was launched in ten states to determine if HCBS could be a cost effective alternative to institutionalization.

1981: OBRA 81 established the Medicaid HCBS Waiver Program, which allowed states to cover home and community-based LTC for the elderly and individuals with disabilities at risk of institutional care.

1990s: Assisted living emerged in the 1990's as the next step of continuing care for people who cannot live independently in a private residence, but who also do not require the 24-hour medical care provided by a nursing home.

1991: The Americans with Disabilities Act came into effect, recognizing that people with disabilities has a right to specific accommodations in housing, employment and public services.

1999: The U.S. Supreme Court rules in Olmstead v. L.C. that the Americans with Disabilities Act (ADA) can, under certain circumstances, require states to provide community-based services to individuals for whom institutional care is inappropriate.

2000: A Federal Older Americans Act amendment created the National Family Caregiver Support program to be operated through the national aging services network.

2001: The New Freedom Initiative was signed by President Bush on February 1, 2001, as part of a nationwide effort to remove barriers to community living for people with disabilities. The initiative called for HHS to promote full access to community life through swift implementation of the Olmstead Supreme Court Decision.

2001: Congress began funding the Real Choice Systems Change Grants for Community Living Program (hereafter, Systems Change grants) to help States change their long-term care systems to rely less on institutional services and to increase access to home and community-based services.

2003: The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 establishes a new Medicare Part D prescription drug program.

2010: The Affordable Care Act includes programs and financial incentives to help states reorient their systems of LTC away institutional care and toward a greater emphasis on HCBS.

Major Factors Driving

Transformational Change 1. Demographic trends that are increasing the demand for LTSS.

2. Economic trends affecting the cost and availability of resources for LTSS.

3. Consumer attitudes and preferences.

4. New research based knowledge and evidence-based practices in LTSS.

5. Conservative movement calling for smaller government and less taxes; more individual and family responsibility; and private-sector market-based solutions to health care needs.

6. Major public policy initiatives that create opportunities and incentives for state and provider organizations such as the Affordable Care Act (ACT) of 2010.

7. Kasich Administration plans to reform Medicaid, which favor risk-based capitated managed care plans.

Assessing the Future Operating Environment

Key Trends

• Skyrocketing health care costs.

• Higher levels of consumer expectation and choice.

• Growing consumer frustration with fragmented health and support systems.

• Shortage of professional caregivers to serve a growing older population

• Continued reliance on family caregivers.

• Medicaid Managed LTSS Movement

• Continued use of capitated payments that are based on quality outcomes

• Increased competition from other health care sectors.

• Continued respect for Area Agencies on Aging.

Assessing the Future Operating Environment

Key Uncertainties

1. WRAAA’s adaptability

2. State’s commitment to maintaining a role for AAAs in Medicaid LTC system

3. Uncertainty of the Affordable Care Act

4. Uncertainty about Older Americas Act Reauthorization/ Amendments and future funding

• Continuing Impact of the Great Recession

• Financial Sustainability related to the high cost of providing LTSS to a growing older population and the unsustainable growth in Medicaid costs.

• Increasing Demand for Publicly Funded Services.

• Consumer empowerment through a consumer-centered approach.

• Collaborative care models that reduce fragmentation.

• Transformation of the Financing and Delivery of LTSS.

– Medicaid Managed LTSS in FY 2013.

– Dual Eligibles

– Consolidation of Medicaid Home and Community-Based Services Waivers.

Major Issues and State Actions in Response to the Changing Environment

Major Issues and State Actions in Response to the Changing Environment

• Continued commitment to home and community-based services and maintaining current service levels.

• Balancing services from institutional to non-institutional settings prioritized

• Changes in LTSS state leadership, agency structure, and staffing.

• Uncertainty surrounding many Affordable Care Act (ACA) LTSS provisions.

Ohio Health and Human Services Transformation Framework

• Modernize Medicaid

• Streamline Health and Human Services

• Improve Health System Performance

Modernize Medicaid

Administration’s Medicaid modernization and cost-containment priorities:– Integrate Medicare and Medicaid benefits (ICDS

for duals)– Expand and streamline home and community-

basedServices (Consolidated HCBS Waiver(s))

Strategic Areas for AAAs

• Maintaining well established and successful role in LTSS (consolidated waiver)– Eligibility - ADRN, PASS, PASRR– Care Management

• Operating in a MME integration world

• Developing New Business Lines

O4A Response

• Responding to ODJFs Request for Information

• Seeking information from other states• Providing input to stakeholders• Informing consumers and providers of

opportunities for input• Suggesting solutions for ICDS that

capitalizes on the strengths of Aging Network

Developing New Business Lines

• Care transitions– Building on relationships with hospitals– Building on relationships with Health Homes /

physician practices– Building on relationships with nursing homes

• Monetizing in-person assessment and case management– MCOs, ACOs, PCMH, Medicaid health Homes

Developing New Ways of Doing Business

• Detailed strategy for streamlining the capabilities of the AAAs and interacting with private for-profit organizations

• Formed a statewide LLC - a mission driven for - profit organization

• Began marketing many services of AAAs to MCOs throughout the state and in the ICDS regions for duals projects

Three Proposed State Initiatives and their Implications for WRAAA

• Update on Plans for a Consolidated Medicaid HCBS Waiver

• Ohio ICDS Proposal

• CMS Balanced Incentive Payment Program (BIPP) Initiative

Consolidated Waiver

• Consolidated waiver includes:– 3 Aging Waivers (PASSPORT, Choices,

Assisted Living) and 2 Physical Disability Waivers (Ohio Home Care and Transitions Waiver)

– Align services and rates across waivers– “On hold” but work continues

Dual Eligible Integration

• Dual eligible integration:– Integrating medical/acute services with

behavior health and LTSS– Previously Dual Eligibles (Medicare and

Medicaid Eligible - MME) were exempt from mandatory Managed care

– Ohio submitted proposal to CMS April 2, 2012 for Integrated Care Delivery System (managed care approach)

Key Elements of Aging Network in Ohio’s ICDS Proposal to CMS

• Front door roles remain the same• All MCOs must contract with AAAs for care

management/service coordination• Provider rates protected 90 days to one year• Consumer may chose CM for LTSS specialists;

PASSPORT care managers are default• ICDS must align with other HHS initiatives (CMS

care transitions program• ICDS may contract with AAAs to do provider

network management, caregiver support, evidenced based disease management

Balanced Incentive Payment Program (BIPP)

• Federal government will increase FMAP 2% if state strives to reach 50/50% balance in costs for institutional versus HCBS ($56 million/year).

• Crosses all ages and disabilities (DD, Aging, Physically disable, MH).

• Ohio applying 2012. • State must agree to conflict free CM; single entry

point/no wrong door; and standardized assessment.

• ADRNs act as single entry point/no wrong door.

AAAs Operating in a Transforming Environment

• Health care delivery is transforming on a federal and state level– Consistent federal and state message on

integrating physical/medical, behavior health and LTSS

• ACA - Incentives for integrating Medicare/Medicaid Eligibles (MMK aka Dual Eligibles or Duals)

• Lowering costs• Improving health outcomes• Balancing HCBS and nursing home care

AAAs Operating in a Transforming Environment

• AAAs have been the leaders in delivering LTSS

• Strengths Include:– Integrating senior services seamlessly in their

local communities– Operating HCBS Aging waivers with high

satisfaction rates, flexibility and proven success

– Bringing innovation to service delivery and community collaborations

AAAs Operating in a Transforming Environment

• Governor’s Office of Health Transformation has many initiatives affecting aging network– Consolidated waiver– Dual Eligible integration (Integrated Care Delivery

System)– Balance Incentive Payment Program– Modernize eligibility determination systems

• Creating new opportunities– Care transition coaching– Monetizing assessment and in-person services– Network management

Thank You!

Ronald Hill, Chief Executive Officer

Western Reserve Area Agency on Agingrhill@psa10a.org

Connect us online at:

www.psa10.org