WRAAA In Transition:
Preparing
for the Future by Building
on the Past
Ronald Hill, CEO
Western Reserve Area Agency on Aging
May 10, 2012
Context for Transitional Change
1.
2.
3.
4.
5.
Agency’s 24 Year History and Evolution
Important Milestones in the Evolution of
HCBS: 1980 - 2012
Major Factors Driving Change In
WRAAA’s Operating Environment
Health Transformation in Ohio Under the
Kasich Administration
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.
2.
3.
4.
5.
6.
7.
Demographic trends that are increasing the demand for LTSS.
Economic trends affecting the cost and availability of resources for
LTSS.
Consumer attitudes and preferences.
New research based knowledge and evidence-based practices in
LTSS.
Conservative movement calling for smaller government and less
taxes; more individual and family responsibility; and private-sector
market-based solutions to health care needs.
Major public policy initiatives that create opportunities and
incentives for state and provider organizations such as the
Affordable Care Act (ACT) of 2010.
Kasich Administration plans to reform Medicaid, which favor riskbased capitated managed care plans.
Assessing the Future
Operating Environment
Key Trends
1.
Skyrocketing health care costs.
2.
Higher levels of consumer expectation and choice.
3.
Growing consumer frustration with fragmented health and support
systems.
4.
Shortage of professional caregivers to serve a growing older
population
5.
Continued reliance on family caregivers.
6.
Medicaid Managed LTSS Movement
7.
Continued use of capitated payments that are based on quality
outcomes
8.
Increased competition from other health care sectors.
9.
Continued respect for Area Agencies on Aging.
Assessing the Future
Operating Environment
Key Uncertainties
1.
2.
3.
4.
WRAAA’s adaptability
State’s commitment to maintaining a role for AAAs in
Medicaid LTC system
Uncertainty of the Affordable Care Act
Uncertainty about Older Americas Act Reauthorization/
Amendments and future funding
Major Issues and State Actions in
Response to the Changing Environment
•
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 consumercentered 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
•
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-based
Services (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 Aging
rhill@psa10a.org
Connect us online at:
www.psa10.org