By Al Norman
One of the biggest opportunities waiting for Gov. Charlie Baker is to more efficiently deliver long term care services for older residents — while at the same time better coordinating those services with the health care system.
MassHealth covers 1.7 million people in Massachusetts, almost one in four people in the state. Roughly 37 percent of the state budget, or $14.7 billion is spent on MassHealth. Of that total, $7.4 billion is spent on MassHealth long-term services and supports (LTSS).
In 2009, the Commonwealth was spending around 55 percent of MassHealth LTSS money on nursing homes. By 2014, the tables were reversed, and 55 percent was being spent on home and community-based care. Because of home care services, the number of nursing home patient days paid for by MassHealth fell by 33 percent between 2000 and 2013.
The state avoided $865 million in nursing home costs by shifting care to cheaper home care settings. We have roughly 25,000 people in nursing facility beds, versus 9,000 seniors in the personal care attendant program, 15,200 elders in MassHealth waivers, and 29,300 older people in the Senior Care Options (SCO) program. There are another 15,000 non-MassHealth elders in the state-funded home care programs.
The fact that nursing facility care is falling is even more remarkable when you consider that the population of people aged 65 and over in Massachusetts, as a percentage of total state population, will jump 50 percent between 2010 and 2030, from 14 percent of the population, to 21 percent of the population.
Yet our LTSS system is far from efficient. Massachusetts has a 46 percent higher nursing facility residency rate than the U.S. average, and hospitals in Massachusetts discharge patients into nursing facilities at a rate 8 percent higher than the U.S. average. Even with our shift away from nursing facility care, we are still placing people in institutions who don’t need to be there, and keeping them there longer than they need to be.
As the state and federal governments turn increasingly to large, managed care companies to cover not only health, but LTSS as well, the major challenge is to make sure that health and LTSS are seen as equally important services, and that LTSS dollars do not get shifted over to pay for health care services. One Senior Care Organization in 2014 received 59 percent of its revenue from Medicaid, yet spent only 5.9 percent of its services on Medicaid home and community based care.
That same plan spent 29 percent of its services on nursing facilities. The Patrick administration has kept these financial analyses under wraps, with no transparency into how billions of dollars in state and federal dollars are being spent.
Part of the problem is that state oversight of LTSS is fragmented. The state agency that has the statutory power to oversee LTSS for older people, the Executive Office of Elder Affairs (EOEA) was informally demoted during the Patrick administration to a Department. The EOEA Secretary lost a seat on the governor’s cabinet, and was stripped of control over institutional services. The Secretary of Elder Affairs now reports to the Secretary of the Executive Office of Health and Human Services (HHS). Yet Chapter 19A, section 1 clearly states that the Secretary of EOEA “shall be responsible for administering and coordinating a comprehensive system of long-term care benefits and services for elderly persons, including institutional, home-based and community-based care and services.” EOEA’s powers were hijacked.
Gov. Baker has the opportunity to create a coordinated system of care that gives seniors the care they want, where they want it: at home. He can also make sure that LTSS does not remain a stepchild of the health care system.
Gov. Patrick leaves office cutting home care funding — just as the state is receiving $110 million in new federal monies to help the state “rebalance” its spending into home and community-based care. If Gov. Baker sees the potential for saving money by giving seniors a better coordinated, transparent system, that protects their civil right to live in “the least restrictive setting” possible, taxpayers and consumers will both be winners under the new administration.
Al Norman is the Executive Director of Mass Home Care. He can be reached at firstname.lastname@example.org