Slide 1

Profile of Massachusetts Populations Needing Long-Term Supports

Presented to the Long-Term Care Financing Advisory Committee
April 17, 2009

Slide 2

Project Team
UMass Medical School/Commonwealth Medicine

Darlene O’Connor, PhD

David B. Centerbar, PhD
Stephanie Anthony, JD, MPH
Cheryl Cumings, MA
Valerie Konar, MBA
Eliza Lake, MSW
Faith Little, MSW, 
Robert Seifert, MPA
Wendy Trafton, MPH

Slide 3

Overview of Profile

	1.	Context for Profile Presentation
	2.	Population Estimates
	a. Current estimates
	b. Projections
	3.	LTS Utilization
	4.	Unmet Need for LTS
	5.	LTS Spending
	6.	Committee Business

Slide 4

Part 1
Context for Presentation

Slide 5 

Working assumptions from March 5th meeting

•	“Community First” is the policy framework for our LTC financing discussion
•	Focus on increasing access to and choice of community LTS while sustaining continuum of care

•	LTS “payer” mix is inadequate and not sustainable

•	Multi-pronged financing approach is necessary
•	Need strong safety net
•	Need to spread risk (through public & private mechanisms)
•	Coverage options must address extent to which LTC is an insurable risk

Slide 6

Working assumptions from March 5th meeting (2)

•	Financing strategies must address opportunities at state level and the need for reform nationally

•	There may be a need for differential financing strategies for elders and under-65 people with disabilities

•	Building public understanding of this issue should be part of the Committee’s work
 
Slide 7

Long-Term Supports (LTS) help people with disabilities meet their daily needs and improve the quality of their lives over an extended period of time.

LTS may be provided at home, in community settings, or in institutional facilities.

A graphic shows the range of intensity of Long-Term Supports.  An arrow is placed above three boxes that runs from the left side of the box to the right side of the box.  It is labeled “Continuum of Long-Term Supports.”  On the left side is a section that says “Medical Services.”  Within this section it says: “Supports can include:  Primary/preventive health care, acute care, post-acute care, home health (post-acute), mental health, hospice, early intervention.”  The middle section says “support for everyday tasks.”  Within this section it says: “supports can include: homemaker, chore, laundry, shopping, meal preparation, home-delivered meals, bill payment, emergency response, transportation, skills training, care coordination.”  The section on the right says says: “Support for self-care tasks.”  Within this section it says: “supports can include: community services such as adult day health, personal care attendant, home health (long-term), residential supports, respite care and institutional services such as nursing facility, intermediate care facilities/MR, chronic & rehabilitation hospitals.”  Along the bottom of the box it says: “education, employment and housing services also are necessary components of successful living for people with disabilities of all ages.”

Slide 8

Many people with disabilities need assistance with everyday tasks and self-care

•	Many people with disabilities need physical assistance or supervision/cueing with one or more of the following:
o	Everyday tasks (e.g., meal preparation, managing medications, managing money, using the telephone, shopping for groceries, skills training, care coordination)
o	Self-care (e.g., eating, bathing, dressing, using the toilet, getting in and out of bed, getting around the home).
•	For purposes of today’s discussion, these people are referred to as having a “LTS Disability.”

Slide 9

The Advisory Committee will focus on financing solutions that will address the needs of people with LTS disabilities

A diagram shows one box representing total people with LTS needs which is ~ 630,000 people.  Three smaller boxes are connected to this larger box.  These three boxes are labeled “Most LTS Needs Met,” “LTS Needs Partially Met,” and “Extent of LTS Needs Unknown.”  These three boxes are connected to a final box which is on the bottom of the page that is labeled “Public Financing Mechanisms,” “Private Financing Mechanisms,” and “Informal Supports.”

Slide 10

Roughly 3% of the 630,000 people with LTS needs have robust LTS coverage through HCBS waiver programs; an estimated additional 56% have many LTS needs met through MassHealth state plan and other state agency services

A pie chart is labeled “People with LTS Needs.”  There are three components of the pie chart: “Most LTS Needs Met” which is listed as 3%, “LTS Needs Partially Met” which is listed as 56% and “Extent of LTS Needs Unknown” which is listed as 41%.

Slide 11
Part 2
Population Estimates

Slide 12

People with disabilities comprise nearly 15% of the total MA population; those with a LTS disability comprise about 10% of the total MA population

A pie chart shows the MA total population five years and older which is a total of 6,074,669 individuals.  According to the American Community Survey, 14.7% of the total population has a disability.  Another pie chart on the right side shows the subset of disability populations in two categories: LTS Disability (e.g., self-care and everyday tasks) and other disabilities.  The category of LTS disability is 10.3% of the total MA population and other disabilities is 4.4% of the total MA population.
Source: 2007 American Community Survey (ACS), U.S. Census Bureau, tabulations by authors.

Slide 13

Approximately half of the people with a LTS disability are age 65 and older, and half are under age 65

A pie chart is labeled “People in MA with LTS Disability, by Age Group (2007).”  The total number of people in MA with a LTS disability age 5 and above is 626,280.  5% of this population is between the ages of 5 and 20 years, 16% are between the age of 21 and 44 years, 32% are between the ages of 45 and 64 years and 47% are 65 years and older.

Source: 2007 American Community Survey (ACS), U.S. Census Bureau, tabulations by authors.

Slide 14

The number of people with a LTS disability is projected to grow by 15% from 2007 to 2020 (compared to 6% growth for the total MA population)

A bar graph is labeled “Persons age 5+ with a LTS Disability in MA, by Age Category.”  
The bar graph shows age projections for years 2007, 2015, and 2020 by age categories 5-20, 21-44, 45-64, 65 and older and all ages 5 and older.  For ages 5-20, there is almost no change in the population projections.  For ages 21-44, there is a very minor decrease in population between 2007 and 2015, which then remains steady through 2020.  For ages 45-64, there is a positive change of approximately 20,000 individuals between 2007 and 2015 then it remains steady through 2020.  For ages 65 and older, there is a positive change of approximately 40,000 individuals between 2007 and 2015 and an additional positive change of approximately 40,000 individuals between 2015 and 2020.  For all ages 5 and older, there is a 15% positive change from 2007 through 2020.

Source: 2007 American Community Survey (ACS), U.S. Census Bureau, tabulations by authors.

Slide 15

Most people turning 65 will need LTS in their lifetimes

On the left is a pie chart labeled “Projected need for LTS by people turning 65 in 2005.”  The pie chart has 5 segments: 1 year or less (17%), 1-2 years (12%), 2-5 years (20%), More than 5 years (20%), and none (31%).  Beneath the pie chart is the following statement: “2 in 5 seniors will need at least 2 years of LTS.” 

On the right is a bar graph labeled “Percent of people using type of care.”  The graph has 5 columns: any LTS (69%), any care at home (65%), formal care at home (42%), any care in facilities (37%), nursing facilities (35%).  Beneath the bar graph is the following statement: “2 in 5 seniors will need formal care at home, and more than a third will spend time in a nursing facility.”

Source:  P. Kemper et al., “Long-Term Care Over an Uncertain Future: What Can Current Retirees Expect?” Inquiry 42:335-30 (Winter 2005/06)

Slide 13

Most people in MA, including those with disabilities have health insurance, (which typically does not cover LTS).  

On the left side is a bar chart labeled “Type of insurance for all insured people in MA, 2008.”  The first column shows “All MA residents (n=6,280,000),” of which, 15% use Medicare, 68% use Employer-Sponsored insurance, and 17% use MassHealth/CommCare/Other Private.  The second column shows “Non-elderly adults (n=3,880,000),” of which, 5% use Medicare, 81% use Employer-Sponsored insurance, and 15% use MassHealth/CommCare/Other Private.  The third column shows “Elderly Adults (n=870,000),” of which, 89% use Medicare, 9% use Employer-Sponsored insurance and 2% use MassHealth/CommCare/Other Private.

On the right side is a bar graph labeled “Type of insurance for insured people disabilities, 2008.”  The first column shows “all people with disabilities,” of which, 34% use Medicare, 45% use employer-sponsored insurance, and 21% use MassHealth, Commonwealth Care or other private insurance.  The second column shows “non-elderly adults with disabilities,” of which, 17% use Medicare, 60% use employer-sponsored insurance, and 24% use MassHealth, Commonwealth Care or other private insurance.  The third column shows “Elderly adults with disabilities” of which, 93% use Medicare and 7% use all other insurances.

Note: Disability status is self-declared.  Population figures (n) are estimates, in thousands.
Source:  Mass. Division of Health Care Finance and Policy

Slide 17

Part 2 Summary Points

There are many types of LTS and they are provided in a variety of settings
The key factors distinguishing LTS are:
Help with everyday tasks or self-care
Needed over an extended period of time
People needing assistance with everyday tasks or self-care are 10% of the total MA population 
About ½ of the people with a LTS disability are elders, and ½ are under 65
While people of any age may need LTS, need tends to increase with age
The population needing LTS will grow dramatically between now and 2020
While most people with disabilities in MA have health insurance coverage, this coverage typically does not cover LTS

Slide 18

Part 3
LTS Service Utilization

Slide 19

Most people with a LTS disability live in community settings

There is a table labeled “LTS Disability Population Age 5 and over, by Setting.”
There are four rows with the following information:
•	549,287 individuals, or 87.7%,  live in non-institutional community settings
•	15,711 individuals, or 2.5%, live in non-institutional group quarters settings
•	61,282 individuals, or 9.8%, live in institutional group quarters settings
•	626,280 individuals, or 100%, live in all settings.
Below the table is a note stating “the ACS data includes individuals in correctional facilities and therefore overstates the number in institutions.

Source: 2007 American Community Survey (ACS), U.S. Census Bureau, tabulations by authors.

Slide 20

People with disabilities, including those with LTS needs, receive community services from state agencies

There is a table with three columns (agency, programs, # served in the community) and eight rows with information about each state agency (DMH, DDS, EOEA, VET, MCB, MCDHH, MRC, DPH).  The table shows the following information:
•	DMH served 27,594 individuals in the community in the following programs:  case management, crisis management, community rehabilitation support, clubhouse, drop-in center, day rehabilitation, day, residential, inpatient, outpatient, reside and educational/employment services.
•	DDS (formerly DMR) served 33,203 individuals in the community in the following programs: service coordination, outreach and education, transportation, Turning 22 program, community residential, facility, individual, family, community day and employment supports.
•	EOEA served 68,880 individuals in the community in the following programs: Home Care Basic, ECOP, and Choices/Frail Elder Waiver.
•	VET served 237 individuals in the community in the following programs:  homeless services, suicide prevention, workforce development, outreach.
•	MCB served 2,986 individuals in the community in the following programs: Independent living social services including orientation and mobility, rehabilitation services, specialized services for children, Turning 22 program, bridge program, vocational rehabilitation including assistive technology and employment supports
•	MCDHH served 5,291 individuals in the community in the following programs: Case management, independent living services, communication access and training services.
•	MRC served 40,116 individuals in the community in the following programs:  Independent living centers, Turning 22, assistive technology, housing registry, supported living, head injury program, protective services, voc. rehab, employment 
•	DPH served 4,748 individuals in the community in the following programs: Early intervention for children with a medical diagnosis that has a high probability for resulting in developmental delay

	•	Below the box a note states “individuals served by DDS, EOEA, and MRC include waiver enrollees."  The data is unduplicated.

Source: MA State Profile Tool, 2009

Slide 21

Elder and disabled MassHealth members use a variety of community LTS

A bar graph is labeled “Number of MassHealth members using selected community LTS, FY 2008”  There are columns showing the number of MassHealth members for ages up to age 65 and over 65 for the following services: HCBS waivers, durable medical equipment, hospice, PCA, Group/Adult Foster Care, Adult Day Health, Home Health, Day Habilitation, Prosthetics, and therapies.  The data from the bar graph follows
•	HCBS waivers were used by approximately 12,200 members age 65 and under and 7,697 aged over 65
•	DME was used by 27,750 members age 65 and under and 17,541 aged over 65
•	Hospice was used by 776 members age 65 and under and 5,617 aged over 65
•	PCA was used by 12,433 members age 65 and under and 5,151 aged over 65
•	Group/Adult Foster Care was used by 2,810 members age 65 and under and 4,920 aged over 65
•	Adult Day Health was used by 2,255 members age 65 and under and 4,244 aged over 65
•	Home Health was used by 16,195 members age 65 and under and 1,946 aged over 65
•	Day Habilitation was used by 6,746 members age 65 and under and 943 aged over 65
•	Prosthetics were used by 7,870 members age 65 and under and 175 aged under 65
•	Therapies were used by 5,635 members age 65 and under and 174 aged under 65
		The total estimated number of MassHealth members receiving LTS in the community for FY08 is 120,508 elders and 192,265 people with disabilities under the age of 65.

Slide 22

The number of community-based elder and disabled MassHealth members is projected to continue to increase

There is a line graph labeled “Historical and Projected Average Number of MassHealth Members, by Age and Setting (SFYs 2003-2014).” Trends are shown from 2003 and projected through 2014 for the following four populations: disabled <65 in the community, elders 65+ in the community, elders 65+ in nursing facilities, disabled <65 in nursing facilities.  The trend for disabled <65 in nursing facilities remains steady at several thousand throughout the timeframe.  The trend for elders 65+ in nursing facilities decreases slightly and steadily from approximately 35,000 individuals in 2003 to approximately 25,000 individuals in 2014.  The trend for elders 65+ in the community increases slightly from approximately 80,000 individuals in 2003 to 100,000 individuals in 2007 and then grows steadily to 180,000 individuals in 2014.  The trend for disabled <65 in the community grows steadily from approximately 170,000 individuals in 2003 to approximately 220,000 individuals in 2014.

Source: MassHealth Office of Finance

Slide 23

Over the past decade, nursing facility bed availability and average census have decreased

This bar graph is labeled “Comparison of MA Licensed Nursing Facility Beds to Census (All Payers), 2000-2008.  The bar graph has bars for years 2000 through 2008 for licensed beds, census, MassHealth, and empty beds.  The graph shows a gradual decline from approximately 54,000 licensed beds to approximately 48,000 licensed beds between years 2000 and 2008.  The graph shows a gradual decline from approximately 49,500 census to approximately 43,000 census between years 2000 and 2008.  The graph shows a gradual decline from approximately 35,000 MassHealth beds to approximately 30,000 MassHealth beds between years 2000 and 2008.  The graph shows a very minor increase in empty beds from years 2000 to 2008.

Under the bar graph, it states “since 2000, the number of licensed beds has decreased 12%, the census has decreased 14%, and the number of empty beds has increased 5%.

Slide 24

Nursing facility admissions continue to rise, matched by the number of discharges – even as the number of occupied beds in MA falls

A bar graph labeled “Nursing Facility Annual Admissions and Discharges and Average Bed Census (All Payers) 1995-2006 (Selected Years)” includes columns for admissions, and discharges for years 1995, 2000, and 2006.  In 1995, there were 67,738 admissions and 67,931 discharges.  In 2000, there were 82,905 admissions and 83,055 discharges.  In 2006, there were 120,394 admissions and 118,444 discharges.  A trend line shows the average census during these years decreasing from 51,733 individuals in 1995 to 49,478 individuals in 2000 to 44,431 individuals in 2006.

Source: DHCFP nursing facility cost reports, with tabulations by Mass Senior Care Association (admissions & discharges); MassHealth Office of LTC (census)

Slide 25

The average length of stay in MA nursing facilities has declined steadily since 1990

A bar graph is labeled “Nursing Facility Median Length of Stay (All Payers), 1988-2006.”  There are ten columns for dates 1988 through 2006 with the following information: (NOTE: not sure of label (days/months/years))
•	For 1988, the length of stay was 2.4
•	For 1990, the length of stay was 2.65
•	For 1992, the length of stay was 2.15
•	For 1994, the length of stay was 1.44
•	For 1998, the length of stay was .75
•	For 2000, the length of stay was .66
•	For 2002, the length of stay was .58
•	For 2004, the length of stay was .49
•	For 2006, the length of stay was .46

Source: State DHCFP, Nursing Facility Cost Reports, 1988-2006

Slide 26

MassHealth nursing facility residents are becoming more frail (1990/1991-2008)

A bar graph shows the percent of total medicaid residents in each acuity category for years 1990/91 and 2008.  For 1990/91, 10% were in category 1 (least frail), 20% in category 2, 20% in category 3, 20% in category 4, 20% in category 5 and 10% in category 6 (most frail).  For 2008, 3% were in category 1 (least frail), 12% in category 2, 18% in category 3, 24% in category 4, 27% in category 5, 16% in category 6 (most frail).

Source: Division of Medical Assistance/MassHealth, Unaudited Management Minutes Score: 1990/91 and 1st Half 2008

Slide 27

Medicare’s proportion of nursing facility residents in MA has increased, while Medicaid’s proportion has decreased

A bar graph is labeled “Change in Nursing Facility Residents by Payer Source (1995 Base Year – 2004).  Bars show change in residents by payer source for Medicaid, Medicare, and Other (mainly private pay) for years 1996, 1998, 2000, 2002 and 2004.  During these 5 year increments, Medicaid had a change of -66 residents in 1996, -494 residents in 1998, -1,186 residents in 2000, -3,517 residents in 2002 and -5513 residents in 2004.  During these 5 year increments, Medicare had an increase of 502 residents in 1996, 1,045 residents in 1998, 628 residents in 2000, 1,384 residents in 2002, and 2,097 residents in 2004.  Additionally, for all other payers there was a change of -459 residents in 1996, -1,221 residents in 1998, -1,476 residents in 2000, -1,935 residents in 2002, and -2,659 residents in 2004.

Source: Mass Extended Care Federation

Slide 28

In 2007, MA had more nursing home beds per capita than about two-thirds of the states

A bar graph labeled “Certified Nursing Home Beds per 1,000 people age 65 and older, 2007” includes columns for all 50 states and the national average.  The columns range from approximately 68 beds per 1,000 people age 65 and older in Iowa to approximately 15 beds per 1,000 people age 65 and older in Alaska.  Massachusetts is ranked #15 from highest to lowest with 54.8 beds per 1,000 people age 65 and older.  The national average is 42.6 beds per 1,000 people age 65 and older.  A note states that “Massachusetts’ relative ranking for beds per 1,000 total population is the same.”

Sources:  Kaiser Family Foundation State Health Facts Online;  U.S. Census Bureau

Slide 29

Based on current numbers, DPH has recently determined that MA has excess nursing facility beds to meet 2015 need

	•	MA is projected to have an average daily bed census of 37,657  nursing facility residents in 2015
	•	Assuming a 95% occupancy rate, this would require 39,639  	nursing facility beds
	•	There are 48,839 beds in the state currently, including 1,572 	beds out of service
	•	Therefore, there would be 10,772 excess beds in 2015

Source: Department of Public Health

Slide 30

Part 3 Summary Points

•	Most people needing LTS live in community settings
•	Community LTS are provided by a variety of state agencies
•	Elder and disabled MassHealth members use a wide range of community LTS
•	The number of community-based elder and disabled MassHealth members is projected to increase

Slide 31

Part 3 Summary Points (2)

•	Nursing facility utilization and average length of stay have declined steadily in the past decade

•	The overall acuity of MA nursing facility residents has increased due to an increase in the acuity of post-acute nursing facility admissions, which is matched by short-stay discharges

•	MA has a higher ratio of nursing facility beds per elder than most states, and a projected excess of over 10,000 beds through 2015

Slide 32

Part 4

Unmet Need for LTS

Slide 33

Many people with a LTS disability have unmet needs

	•	 A study of children with special health care needs found that over 10% of children had unmet needs for home health care, mental health care, substance abuse treatment, communication aids and professional care coordination (KS Hill, 2008)

	•	 A study of adults with disabilities in MA found that many people with ADL and IADL needs did not receive help (DPH, 2007)

	•	 A study of dual eligible elders 65 yrs and older found that while 64% receive home care, 55% still have unmet need for help with ADLs (Komisar, Feder, Kasper, 2005)

Source: Kristen Hill, et all. Unmet Need among Children with Special Health Care Needs in Massachusetts.  Matern Child Health J (2008) 12.
DPH, Study of the Unmet Needs of Adults with Disabilities in Massachusetts, 2007. 
Harriet Komisar, Judy Feder, Judith Kasper.  Unmet Long-Term Care Needs: An Analysis of Medicare-Medicaid Dual Eligibles.  Inquiry 42: 171-182 (Sum 2005). 

Slide 34

In MA, many people who receive assistance with LTS need more help; some people who need LTS receive no assistance at all

A bar graph shows the percent of adults with disabilities who need more help with ADLs and IADLS and the percent of adults with disabilities who need help but do not receive any assistance with ADLs and IADLs.  A note on the graph states “N=571 adults age 18-59 with disabilities (self-identified). For the columns showing percent of adults with disabilities who need more help, the data points are:
•	51% need more help with heavy housework.
•	37% need more help with shopping.
•	53% need more help with light housework.
•	35% need more help with managing money.
•	49% need more help with preparing own meals.
•	29% need more help with walking.
•	33% need more help with transferring.
•	27% need more help with bathing and showering.
•	14% need more help with dressing.
•	3% need more help with eating.
•	32% need more help with using the toilet.

For the columns showing percent of adults with disabilities who need help but do not receive any assistance, the data points are:
•	15% need help with heavy housework.
•	6% need help with shopping.
•	9% need help with light housework.
•	6% need help with managing money.
•	3% need help with preparing own meals.
•	18% need help with walking.
•	8% need help with transferring.
•	6% need help with bathing and showering.
•	2% need help with dressing.
•	2% need help with eating.
•	3% need help with using the toilet.

Source:  DPH, Study of the Unmet Needs of Adults with Disabilities in Massachusetts, 2007

Slide 35

Reasons for unmet need include inability to pay or find help and not wanting to ask friends and family

A pie chart is labeled “Prevalance of Unmet Need for Personal Assistance Services Among Persons 50+ with Disabilities in U.S."  This graphically shows the results of an AARP study that concluded 43% of people with disabilities age 50 and over had sufficient help with needs met, 28% had needs met with no help needed and 29% had unmet needs.  70% of respondents stated inability to pay as the reason for having unmet needs.  10% of respondents stated an inability to find help.  10% or respondents stated that they did not want to ask family and friends for help.  The final 10% stated varied answers and this group is titled "other" in the pie chart.

Source: Mary Jo Gibson, S. Verma. Just Getting By: Unmet Need for PAS Among Persons 50 or Older with Disabilities.  AARP Public Policy Institute.   

Slide 36
 
Gaps in existing access to publicly-funded community LTS contribute to unmet need

	•	 Across state programs, there is uneven access to LTS depending on diagnosis, age and income status
  
	•	 Only three populations are eligible for any HCBS
   	 waiver services:
	• children with autism, 
	elders,
	• persons with mental retardation, and
	• persons with traumatic brain injury.
  
	•	Individuals who have developmental disabilities (not MR), age into or acquire disabilities (including brain injury) have less or no access to services

Slide 37

Part 4 Summary Points

	•	Studies in MA show that people with disabilities across all age groups have unmet needs – the degree of unmet need varies by population and service category

	•	More people receive some assistance, but need more help (“under-assisted”), than receive no assistance at all (“unassisted”)

	•	For people with disabilities age 50 and over, the primary reason for having unmet need for personal assistance services is the inability to pay

	•	Gaps in access to publicly-funded community LTS, due to program eligibility that varies by diagnosis, age and income, contributes to unmet need

Slide 38

Part 5
LTS Spending

Slide 39

Nationally, Medicaid and informal caregivers support the majority of LTS
•	Of all paid LTS:
o	Medicaid is the primary payer of LTS for people with disabilities of all ages (48.9%)
•	Medicare pays relatively little for LTS (20.4%)
o	Roughly 13% ($42.4 billion) of the $329 billion in total Medicare spending in 2005 was for LTS
o	Of the $42.4 billion, 47% is for skilled nursing facility, 31% is for home health agencies, and 12% is for other fee-for-service LTS (e.g. hospice, DME, rehab hospitals.)
	•	Private LTC insurance is small (7.2%), but may be able to grow
	•	Out-of-pocket expenses are significant (18.1%) and expected to grow by 25-50% by 2015

Though often not counted in LTS expenditures, informal caregivers (unpaid) provide the majority of LTS – one study estimated  that informal care equaled  36% of the total value of care for elders.

Slide 40

State expenditures for LTS are spread across several agencies

Two pie charts show agency spending as a % of total spending in both community and institutional settings.  The pie chart on the left shows each agency’s % of community spending.   The data points are as follows:
•	MassHealth Long-Term Care State Plan– 39.5%
•	DDS (formerly DMR) – 33.4%
•	DMH – 12.6%
•	EOEA – 8.7%
•	MRC – 3.3%
•	VET – 1.1%
•	MCB – 0.7 %
•	DPH – 0.6%
•	MCDHH – 0.1%
Total spending is $2,887,171,375

The pie chart on the right shows each agency’s % of institutional spending.  The data points are as follows:
•	MassHealth Nursing Facility – 81.1%
•	DDS (formerly DMR) – 8.6%
•	DMH – 8%
•	MCB – 1.4%
•	DESE – 0.6%
•	VET – 0.3%
•	MRC – 0.1%
Total spending is $2,128,539,714

Note: MassHealth collects federal Medicaid matching funds for a significant portion of LTS expenditures made by other agencies for Medicaid members.  All $ are SFY08, except for MH Nursing Facility, which is SFY07.

Source: MA Executive Office of Health and Human Services

Slide 41

MA nursing facilities are disproportionately dependent on Medicaid.

There is a pie chart labeled "MA Nursing Home Payer Mix."  The chart shows that Medicaid is the primary payer at 65% of all dollars.  The other payers listed are: 
Medicare, which pays 15%
Private, which amounts to a total of 14%
Other, which amounts to a total of 5%

Source: Massachusetts Senior Care Association, 2009.

Slide 42

Shift in MassHealth spending from institutions to communities reflects the State’s Community First policy

A bar graph labeled “MassHealth Nursing Facility Spending as a Percent of Total MassHealth Long-Term Care Spending (in billions)” has 6 columns for FY 2003 – FY 2008 which show an increase from 27% spent in community settings in FY 2003 to 40% spent in community settings in FY 2008.  In FY 2003, total spending was approximately $2.2 billion, of which, 27% was in community settings and 73% was in institutional settings.  In FY 2004, total spending was approximately $2.35 billion, of which, 28% was in community settings and 72% was in institutional settings.  In FY 2005, total spending was approximately $2.45 billion, of which, 29% was in community settings and 71% was in institutional settings.  In FY 2006, total spending was approximately $2.55 billion, of which, 32% was in community settings and 68% was in institutional settings.  In FY 2007, total spending was approximately $2.65 billion, of which, 36% was in community settings and 64% was in institutional settings.  In FY 2008, total spending was approximately $2.8 billion, of which, 40% was in community settings and 60% was in institutional settings.  

Source: MassHealth Budget Office.  These expenditures do not include spending on HCBS waivers.

Slide 43

MassHealth Spending on selected community LTS has increased substantially over the past five years

A bar graph is labeled " MassHealth Spending on Select Community Services FY2004 & FY2008, by Age."  The first service, PCA, increased from $233 million to $316 million between 2004 and 2008.  In 2004, $176 million was spent on services to individuals under age 65.  $57 million was spent on services to individuals age 65 and older.  In 2008, $243 million was spent on services to individuals under age 65.  $73 million was spent on individuals age 65 and older.  The next service, Adult foster care/Group, increased from $65 million in 2004 to $89 million in 2008.  In 2004, $26 million was spent on services to individual under age 65.  $39 million was spent on services to individuals age 65 and older.  In 2008, $31 million was spent on services to individuals under age 65.  $58 million was spent on services to individuals age 65 and older.   The next service, Adult Day Health, increased from $39 million to $62 million between 2004 and 2008.  In 2004, $15 million was spent on services to individuals under age 52.  $23 million was spent on services to individuals age 65 and older.  In 2008, $15 million was spent on services to individuals under age 65.  $47 million was spent on services to individuals age 65 and older.  The next service, Day Habilitation, increased from $83 million in 2004 to $113 million in 2008.  In 2004, $73 million was spent on services to individuals under age 65.  $10 million was spent on services to individuals age 65 and older.  In 2008, $100 million was spent on services to individuals under age 65.  $10 million was spent on services to individuals age 65 and older.

Source: MassHealth Budget Office

Slide 44

Part 5 
Summary Points

•	LTS currently are a shared public and private responsibility

•	Informal caregivers provide a significant amount of LTS

•	Several state programs pay for both community and institutional LTS, although MassHealth pays for the majority of institutional LTS

•	Public LTS spending is still weighted heavily toward institutional care, but community LTS is increasing.

Slide 45

Part 6
Committee Business

Slide 46

Committee Business

•	Public communications plan
•	Participation of Dr. Connie Garner in May
•	Past issues raised (e.g. additional AC sessions; additional experts; administrative structures discussion)
•	Detailed data profile with technical notes is forthcoming
•	Parking reimbursement instructions
•	Next meeting
o	Date and Time: Friday, May 15th, 2009 from 9 AM – 11:30 AM
o	Location: 21st floor of One Ashburton Place