Appendix 8. CMS Presentation to the Subcommittee

National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible adults

Lekisha Daniel-Robinson and Anita Yuskauskas made the following slide presentation to the Subcommittee entitled "Medicaid Adult Quality Measures: Understanding the Target Population." Select to access the PowerPoint Version [ Microsoft PowerPoint file - 1.61 MB] .

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Medicaid Adult Quality Measures: Understanding the Target Population

Lekisha Daniel-Robinson, MSPH
Division of Quality, Evaluation, and Health Outcomes
Family and Children's Health Programs Group
Center for Medicaid, CHIP and Survey & Certification

Anita Yuskauskas, PhD
Disabled and Elderly Health Programs Group
Center for Medicaid, CHIP and Survey & Certification

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The Center for Medicaid, CHIP and Survey & Certification: Our Mission

  • To help States make Medicaid and CHIP the best programs they can be and to contribute to the broader goal of improving health care for all Americans
  • Beneficiaries are our focus
  • Partnerships are critical to success

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Identifying a Core Set of Quality Measures for Adults in Medicaid

MonthEvents
October 201010/18/10      1st meeting of AHRQ's Subcommittee to the National Advisory Council
10/25/10      Medicaid listening session for State comments on SNAC recommended core measures set
November/December 201011/02/10      Stakeholder Listening Sessions
12/30/10      Publication of Federal Register Notice on the recommended core measures set
March 201103/01/11      Public comment period end for the Federal Register Notice on recommended core measures set
May/June/July 2011TBD      2nd meeting of AHRQ's SNAC to discuss final recommendations for core measures set
07/30/11      Prioritization for measure enhancement and development
December 201112/30/11      Initial core set published for use by States and other stakeholders
January 201201/01/12      Adult Quality Measures Program

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Medicaid's Influence in the Health Care Market

  • Health insurance coverage
    • ~60 Million children, adults, elderly, including people with physical, developmental, and intellectual disabilities.
  • Assistance to Medicare Beneficiaries
    • 8.8 Million elderly and people with disabilities (19% dual eligible)
  • Long-term care Assistance
    • Medicaid pays for 40% of long-term care services
    • 1 Million nursing home residents
    • 2.8 Million community-based residents

Source: Kaiser Family Foundation, based on 2003 Medicare Current Beneficiary Survey (MCBS) and the 2003 Medicaid Statistical Information System (MSIS) Summary File.

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Medicaid and CHIP Enrollment by Eligibility Category, FY 2009 (Unduplicated annual enrollment)

Image: Pie chart shows the following enrollment data for fiscal year 2009:

  • Children: 49%
  • Elderly, Over 65 years: 8=9%
  • Blind/Disabled Adults, Under 65 years: 15%
  • Other Adults, Under 65% years: 27%

Notes:

  • State Medicaid programs use a variety of service delivery systems:
    • Roughly 70% of Medicaid population is in some sort of managed care arrangement (i.e., managed care, primary care case management).
    • A large portion of Medicaid enrollees with multiple chronic conditions and complex health care needs receive care in a fee-for-service setting.
  • 25.3% of our beneficiaries in Medicaid are elderly and disabled.

Source: U.S. Dept of Health and Human Services, 2009 CMS Statistics; CMS Pub. No.034497 08/2009.

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Medicaid and CHIP Enrollees by Age, FY 2006*

AgeNumberPercent of Medicaid Population
Under 2132.354%
21-6421.1 million35.4%
65+6.1 million10.2%
Unknown.1 million0.2%
Total:59.6 million

Almost 27 Million are Adults (21 and older)

*Enrolled at some point during fiscal year.

Source: US Dept of Health and Human Services, 2009 CMS Statistics; CMS Pub. No.034497 08/2009.

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Understanding the Adult Medicaid Population: Overall Adult Health (under 65 yrs)

  • One in five Medicaid adults (men & women) describe their general health as fair or poor.
  • One in seven Medicaid adults (men & women) have fair or poor mental health.
  • 2009 Government Office of Accountability study found that adult Medicaid enrollees ages 21-64:
    • Majority had at least one potentially serious health condition.
    • 57 % were overweight, had diabetes, high cholesterol, high blood pressure, or a combination of these conditions.
    • Twice as likely to have diabetes compared to privately insured adults (13:7).

Sources: Kaiser Family Foundation: Low-Income Adults Under Age 65—Many are Poor, Sick, and Uninsured, June 2009. Government Office on Accountability: Study on Medicaid Preventive Services, August 2009.

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Understanding the Adult Medicaid Population: Maternal & Reproductive Health

  • Women comprise the majority of the adult Medicaid population.
  • Nearly 2 of 3 of adult women on Medicaid are in their reproductive years (19-44).
  • Medicaid covers 4 of 10 births and approximately 2 of 3 publically-funded family planning services, including:
    • Prenatal and post-partum care
    • Gynecological services
    • Testing and treatment of sexually transmitted diseases

Sources: National Institute for Reproductive Health
Kaiser Family Foundation: Health Reform: Implications for Women's Access to Coverage and Care, December 2009.

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Understanding the Adult Medicaid Population: Complex Health Care Needs

  • People with intellectual, physical, & developmental disabilities as well as the dually-eligible often have complex health care needs.
  • Non-elderly Medicaid enrollees with disabilities are more likely to have 3+ chronic conditions (e.g., cardiovascular, psychiatric, central nervous system conditions) than enrollees without disabilities.
  • People eligible for both Medicaid/Medicare are referred to as the "Duals":
    • 3 in 5 dually-eligible have multiple chronic conditions.
    • Roughly 37% have cardiovascular disease.
    • 20% have 1+ mental cognitive condition (i.e., Alzheimer's disease, other dementia).

Sources: CHCS: The Faces of Medicaid II Recognizing the Care Needs of People with Multiple Chronic Conditions, October 2007. The Kaiser Family Foundation: Chronic Disease and Co-Morbidity Among Dual Eligibles: Implications for Patterns of Medicaid and Medicare Service Use and Spending, July 2010.

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Understanding the Adult Medicaid Population: Adults and the Elderly with Long-term Care Needs

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Percentage of Total Medicaid Expenditures for Older Adults and Persons with Disabilities, FFY 1980-2005

Image: Chart compares expenditures in billions from 1980 to 2005 for the aged and disabled. Expenditures for the disabled remain around 70% throughout this period; expenditure for the aged have lowered slightly from just below 40% in 1980 to 30% in 2005.

Notes: Since 1980, the percentage of total Medicaid expenditures for 25% of the beneficiaries has been relatively steady at 70%. This includes all Medicaid expenditures—primary and LTC supports and services.

Source: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index.

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Long-Term Care Expenditures by Payer: United States, 2005

Image: Pie chart shows the following expenditure data by payer:

  • Medicaid: 48.9%
  • Medicare: 20.4%
  • Out-of-Pocket: 18.1%
  • Private Insurance: 7.2%
  • Other Private: 2.7%
  • Other Public: 2.6%

Notes: Medicaid is the largest payor of LTC in the U.S., paying for about half of all LTC in the U.S. The LTC includes both institutional and community services.

Source: Georgetown University Long-Term Care Financing Project.

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Medicaid Institutional and Community-Based Expenditures in Dollars, FFY 1980-2005

Image: Bar graph shows the following expenditure data:

Institutional:

  • 1980: $27 billion
  • 1985: $34 billion
  • 1990: $42 billion
  • 1995: $55 billion
  • 2000: $59 billion
  • 2005: $59 billion

Community:

  • 1980: $1 billion
  • 1985: $3 billion
  • 1990: $6 billion
  • 1995: $13 billion
  • 2000: $22 billion
  • 2005: $35 billion

Notes: Spending for community-based long-term care services rose to 45% of all Medicaid long-term care costs. So it is almost equal to that of institutional care.

In FY 2008, long-term care represented 32.1 percent of total Medicaid spending, which equaled $331.8 billion. More than half of those expenditures remain in institutional settings, with some States still spending more than 2/3 of their long term care resources in institutional settings.

Source: CMS Form 64 Reports, adjusted for price increases based on the Skilled Nursing Facility Input Price Index.

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Describing Medicaid LTC Population Using HCBS

  • Large: 2.2 million individuals
  • 2/3 dually eligible for Medicare and Medicaid
  • Mean age 56; 61% female
  • Diverse: Tremendous State variation in characteristics of the HCBS population
  • Subpopulations, average percentage of the HCBS population:
    • I/DD: 26%
    • SMI: 13%
    • Under 65 with physical disability: 24%
    • 65+: 44%

Source: MAX and MedPAR data, 2005

  • I/DD (Intellectual/Developmental Disabilities)
    • Enrollment in an I/DD or mental retardation (MR)/DD waiver, use of an intermediate care facility (ICF)-MR, or relevant diagnosis codes on inpatient or HCBS service records
  • SMI (Serious Mental Illness)
    • Enrollment in an MI waiver, use of an inpatient psychiatric facility, or relevant diagnosis codes on inpatient or HCBS service records
  • 65+
    • All HCBS participants who are 65 or older
  • Under 65 with physical disability
    • All others who are under age 65 (includes, for example, traumatic brain injury and HIV)
  • Notes: Overlap among I/DD, SMI, and 65+ allowed
    • Also includes: Subset of Developmental Disabilities Group (autism, CP)
    • Brain Injury
    • Dementia
    • Stroke
    • Subset of Mental Illness
    • Subset of Medically Fragile Conditions

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Medicaid LTC Beneficiaries (in millions), 2003

Image: Pie chart shows the following data:

  • Community services: 1.69
  • Institutions: 1.62

Note: A majority of people receiving Medicaid LTC are in community settings.

Sources: CMS Medicaid Statistical Information System State Summary Datamart and Kaiser Family Foundation. The community services total includes personal care and HCBS waiver beneficiaries. This total may include duplicates.

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Medicaid LTC Spending Distributed by Target Population, FFY 2005

Image: Pie chart shows the following data:

  • A/D: 68.6%
  • DD: 30.8%
  • Other: 0.6%

Note: Most long-term care supports two major population groups, older adults and people with physical disabilities (aged/disabled or A/D) or people with developmental disabilities (DD).

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Challenges Defining the Medicaid LTC Population

  • Wide variety of diagnostic categories in LTC
  • Wide range of settings
  • Wide range of service provider types and qualifications
  • Wide range of measurement sets: no standardization
  • No standard "treatment intervention", i.e., service definitions & service delivery models

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LTC: Social & Needs-Based Service Delivery System

  • Generally consists of services and supports to address chronic & long term conditions
  • Promotes maximum qualities of life in community settings
  • Not primary health care
  • Services can include:
    • Personal Care
    • Home Health (nursing, medical supplies & equipment, appliances for home use, optional PT/OT/Speech/Audiology
    • Rehabilitative Services
    • Targeted Case Management
    • Self-directed Personal Care
    • HCBS for the Elderly & Disabled
    • Other

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Ongoing HCBS Measurement Efforts at CMS

  • 1915(c) Assurance-Based Measures
    • The assurances relate to six domains:
      • Level of Care; Plan of Care; Health and Welfare; Provider Qualifications, Administrative Authority; Financial Accountability
    • Performance measures will directly align with assurances
  • MFP Longitudinal QOL survey on all MFP participants
    • Tracking changes from institution through the first two years in community.
    • Domains include living situation, choice and control, access to personal care, respect/dignity, community integration/inclusion, overall life satisfaction, health status.
    • Individual level outcomes for quality of care: subset of DRA health and welfare clinical outcomes.
  • HCBS Experience Survey (CAHPS®)—Kicked off June 2010
    • Experience of care measures

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Ongoing HCBS Measurement Efforts at CMS

  • National Balancing Indicator Project
    • Measure states' progress in providing a person-centered, balanced system of long-term services and supports.
    • 18 LTSS indicators based on six domains:
      • Sustainability
      • Self-Determination/Person Centeredness
      • Prevention
      • Community Integration & Inclusion
      • Shared Accountability
      • Coordination & Transparency

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The "Triple Aim"

Image: A triangle is shown with the following text in boxes at the three points:

  • Population Health
  • Experience of Care
  • Per Capita Cost
Current as of December 2010
Internet Citation: Appendix 8. CMS Presentation to the Subcommittee: National Advisory Council Subcommittee: Identifying Quality Measures for Medicaid-eligible adults. December 2010. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/news/events/nac/reports/nacqm/appendix8.html