My WPRI.com piece Monday on 12 things to know about Medicaid in Rhode Island has – happily! – gotten a lot more clicks and feedback than I expected. Thanks to all who read it.
The most interesting feedback I received was from Kali Thomas, an assistant professor of health services, policy and practice at Brown University, who thinks there are ways Rhode Island can reduce its far-above-average Medicaid spending on elderly residents:
I wanted to point out some interesting information about those highest spenders you referenced (particularly those in nursing homes).
One disappointing statistic is that we are ranked 43rd out of the 50 states with almost one-fifth of our population of nursing home residents identified as having low-care needs. These “low-care” residents are those who do not necessarily require the level of care provided in nursing homes. Specifically, they do not require assistance with any of the four late-loss activities of daily living – eating, bathing, toileting, or transferring – and they are not classified as needing extensive rehabilitation or identified as “clinically complex.” This suggests that were we able to provide them with supportive services in the community, they may be able to be cared for and sustained in a less restrictive and more appropriate setting. Focusing on efforts to reduce the numbers of low-care residents in our state is a great opportunity to reduce the excessive spending in our Medicaid program.
Previous work I have conducted with colleagues at Brown’s School of Public Health suggests that increased spending on home- and community-based programs, like home-delivered meals, is related to a lower proportion of low-care residents. Further analyses have suggested that increasing capacity in the home-delivered meals program can potentially result in savings to states’ Medicaid programs. However, despite legislative testimony I gave this past year highlighting the beneficial effects we could recognize by reinstating previous funding levels for our state’s Meals on Wheels program, the cuts that were made to the program have sadly remained in place.
I would like to draw attention to A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caregivers, produced by AARP, SCAN Foundation and the Commonwealth Fund. It lists specific domains related to long-term care where we could use improvement and how we compare to other states. For example, Rhode Island ranks second to last in our efforts to re-balance Medicaid long-term care spending. As a state, only 16% of our Medicaid long-term care spending goes toward services provided in people’s home and in the community. Investing in relatively more affordable supportive services that enable people to remain in the community rather than being placed in costly nursing homes is one way we can lower overall costs. I believe that our state’s residents and policymakers need to have a better awareness of why we are among the highest spenders on long-term care and what we can do about it.
There is so much we can learn from other states and with our size, we are ideally positioned to enact changes to improve our system of long-term services and supports. Thank you for spreading awareness about our state’s Medicaid spending “problem.” Now, let’s focus on solutions!
Another interesting point was made by Secretary of Health and Human Services Steven Costantino, who pointed me to this July study by Pew looking at state Medicaid costs nationwide.
The Pew study shows Medicaid spending growth in Rhode Island averaged just 2% from 2000 to 2012, the third-lowest growth rate in the country and only half the national average of 4.1%. That’s far below the 7% growth rate for Medicaid spending projected last month by the House Fiscal Office.
The study also shows Medicaid spending per enrollee rose 13% in Rhode Island between 2000 and 2010, more than twice the national average of 13%. Also interesting: 33% of Rhode Island’s Medicaid enrollees were elderly and disabled, tied for fifth-highest share in the country.
Finally, if you want to dig in further on all these issues, you’ll want to read this 2007 “Future of Medicaid” report conducted by the Carcieri administration. It’s a very good overviews of the issues Medicaid was facing in Rhode Island pre-recession and pre-Obamacare, and has some terrific charts. For example, here’s another look at how Medicaid costs breakdown across elderly beneficiaries during the state’s 2005-06 fiscal year:
One of the many challenges noted in the report: “Medicaid beneficiaries in mandatory coverage groups tend to be high-need, high-cost service utilizers. As is explained elsewhere in this report, by contrast, beneficiaries in the optional coverage groups are primarily children and families – e.g., RIte Care enrollees – who have less complex service needs and are less costly to cover.” It goes on to say:
Of critical importance is that recent efforts by the state to improve services to the adult populations “carved out” many of the high cost beneficiaries and focused instead on managing the care of users at the middle and lower ends of the cost distribution curve. This includes the soon to be implemented health plans for both elders and adults with disabilities. Yet, as these distribution curves reveal, care management is necessary for all beneficiaries and, in particular, for those who are high cost users, to ensure that the right services are being provided in the most appropriate setting.
And here’s another chart from that report, this one showing how fast RIte Care and RIte Share, the managed-care insurance program for lower-income children and adults, expanded during the Almond administration: