June 2010
Prepared for: Genworth Financial
Lewin contact: Lisa Alecxih
A number of factors will likely result in dramatic changes to the financing and delivery of long-term care (LTC) services—an increasing population of older people and people with disabilities, a severe economic recession, the new national health reform law, and other recent developments. This study, conducted by The Lewin Group for Genworth Financial, synthesizes the latest available data on Medicaid and LTC trends; takes a new look at LTC financing challenges and possible solutions in light of these historic changes; and proposes guidelines for consideration in developing a comprehensive, national long-term care solution.
Client Area: Payers / Insurers
Expertise Area: Aging and Disability
May 2010
Prepared for the Congress of California Seniors
Lewin Contact: Lisa Alecxih
This study estimates the potential State revenue impacts associated with the proposed elimination of the Medi-Cal ADHC program. While the proposed elimination of the Medi-Cal ADHC program would save direct expenses on the program, policymakers should also consider the potential negative impacts of the elimination on cost-shifting to other more expensive care settings, loss of jobs among ADHC employees, reductions in family caregivers’ ability to work, loss of State tax revenue, forfeiting $164 million annually in federal Medicaid matching funds and economic impact on local businesses and other entities that would lose revenue from the elimination of adult day health care providers.
Client Area: Foundations, State and Local Governments
Expertise Area: Aging and Disability
February 2010
DHHS, Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Lewin contact: Lisa Alecxih
On January 28, the Engelberg Center for Health Care Reform at Brookings hosted a forum to discuss strategies for improving care for older Americans across a range of institutional and community-based settings. Experts and key stakeholders examined the components of health care reform most likely to influence older Americans; discussed promising models for payment, delivery-system reforms, and coordination across a continuum of care; and identified how quality and efficiency can be improved.
During the forum, Richard Frank, Deputy Assistant Secretary for Office of Disability, Aging, and Long-Term Care Policy for the Assistant Secretary for Planning and Evaluation, officially released a chartbook prepared by The Lewin Group. The chartbook takes a closer look at the health spending for individuals with chronic conditions and functional impairments living in the community. The Lewin Group analysis indicates that the combination of chronic conditions and functional limitations is a critical indicator and an improved targeting criteria for individuals with high health spending who could benefit from better coordination and management.
Client Area: Federal Government
Expertise Area: Aging and Disability
July 2009
Minnesota Department of Human Services
Lewin contact: Kathy Kuhmerker
The Minnesota Department of Human Services (DHS), Disability Services Division contracted with The Lewin Group to conduct a study of the infrastructure of the State’s Medical Assistance State Plan Personal Care Assistance (PCA) program. Lewin partnered with the University of Minnesota’s Institute on Community Integration on this study.
This final report analyzes the drivers of Medical Assistance expenditures in the State’s PCA program and provides recommendations to strengthen the program. While the study focuses primarily on PCA State Plan services, important considerations include how other Medical Assistance Programs (e.g., home and community-based waiver programs) provide PCA services, and the interaction between those program requirements and the PCA State Plan program.
Three interim reports were also developed for this project and are posted on this website as well:
- Interim Report #1 (dated March 31, 2009) provided a national scan of PCA programs, analyses of Minnesota PCA program enrollment and expenditure data, findings from interviews with State officials in Minnesota and other states with PCA programs, findings from stakeholder interviews, and preliminary recommendations for the State.
- Interim Report #2 (dated June 24, 2009) included findings from a series of 14 focus groups, conducted by the
University of Minnesota’s Institute on Community Integration, with recipients of PCA services and PCA workers in a variety of Minnesota Medical Assistance programs offering PCA services. The purpose of conducting these focus groups was to hear from workers about their experiences providing PCA services and from service recipients about their experiences receiving PCA services. - Interim Report #3 (dated June 25, 2009) presented provider agency perspectives and related recommendations to strengthen and improve provider-related components of the program based on a survey of PCA provider agencies. This report also included analyses of the types of living arrangements .
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
June 2009
Minnesota Department of Human Services
Lewin contact: Kathy Kuhmerker
The Minnesota Department of Human Services (DHS), Disability Services Division contracted with The Lewin Group to conduct a study of the infrastructure of the State’s Medicaid State Plan Personal Care Assistance (PCA) program. This study analyzes the drivers of Medical Assistance expenditures in the State’s PCA program and provides recommendations to inform legislation to strengthen the PCA program.
This report is the last of several interim reports that Lewin submitted to DHS, in addition to a comprehensive final report. This report focuses on provider agency perspectives and related recommendations to strengthen and improve provider-related components of the program, and analyses of the types of living arrangements in which individuals receive PCA services and related recommendations.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
June 2009
Minnesota Department of Human Services
Lewin contact: Kathy Kuhmerker
The Minnesota Department of Human Services (DHS), Disability Services Division contracted with The Lewin Group to conduct a study of the infrastructure of the State’s Medicaid State Plan Personal Care Assistance (PCA) program. This study analyzes the drivers of Medical Assistance expenditures in the State’s PCA program and provides recommendations to inform legislation to strengthen the PCA program.
This report is the second of several interim reports that Lewin submitted to DHS, in addition to a comprehensive final report. This second report includes findings from a series of 14 focus groups, conducted by the University of Minnesota’s Institute on Community Integration, with recipients of PCA services and PCA workers in a variety of Minnesota Medical Assistance programs offering PCA services. The purpose of conducting these focus groups was to hear from workers about their experiences providing PCA services, and from service recipients about their experiences receiving PCA services. This report provides: a description of the methodology used to obtain this data (through the focus groups); findings from several topical areas such as services delivered/received, quality of services, wages/benefits, education/training, and family members as PCA workers; a summary of focus group participants’ recommended key changes to improve the Minnesota PCA program; and interim recommendations to improve and strengthen Minnesota’s PCA program.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
March 2009
Minnesota Department of Human Services
Lewin contact: Kathy Kuhmerker
The Minnesota Department of Human Services (DHS), Disability Services Division contracted with The Lewin Group to conduct a study of the infrastructure of the State’s Medicaid State Plan Personal Care Assistance (PCA) program. This study analyzes the drivers of Medical Assistance expenditures in the State’s PCA program and provides recommendations to inform legislation to strengthen the PCA program.
This report is the first of several interim reports that Lewin submitted to DHS, in addition to a comprehensive final report. This first report includes findings from a national scan of PCA programs, analysis of Minnesota PCA program enrollment and expenditure data, interviews with state officials in Minnesota and other states with PCA programs, stakeholder interviews, and initial recommendations for the State.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
March 2009
AARP
Lewin contact: Lisa Alecxih
AARP commissioned The Lewin Group to conduct research to help inform policy discussions about quality of care and litigation in Tennessee nursing homes. Specifically, the study addresses the following overarching policy questions: What are the factors driving litigation in Tennessee? What are the nursing home litigation trends in the state? What positive or negative outcomes does litigation have for nursing home residents? What steps have nursing facility operators in Tennessee taken to reduce the frequency and cost of litigation, and what are the implications for nursing home quality? What are the potential impacts of tort restrictions, based on the experiences of other states?
Based on the findings, the report discusses considerations and potential strategies for ensuring delivery of quality services in Tennessee nursing homes.
Client Area: Associations
Expertise Area: Aging and Disability
November 2006
Lewin contact: Lisa Alecxih
Over the past 20 years, a significant number of senior citizens, particularly among the “oldest old” – persons 85 and older - have been choosing to stay in their homes rather than move to nursing homes, according to a study by The Lewin Group.
The full report on this latest research by The Lewin Group was released at a news conference by Lisa Alecxih, Vice President at The Lewin Group, on Tuesday, November 21. The report takes an in-depth look at trends among America's large and growing senior population.
Expertise Area: Aging and Disability
May 2006
DHHS, Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Lewin contact: Lisa Alecxih
In an effort to improve the quality of care provided in long-term care settings, as well as ensure a committed and qualified long-term care workforce, the Office of the Assistant Secretary for Planning and Evaluation, within the U.S. Department of Health and Human Services, contracted with The Lewin Group to study the efficacy of various approaches to pre-employment screening and on-the-job monitoring of nurse assistants to prevent resident abuse in nursing homes. The two primary methods used for pre-employment screening include checking nurse aide registries and conducting criminal background checks. Federal guidelines require each state to establish and maintain a registry of nurse aides that includes certification information and substantiated findings of abuse, neglect, or financial exploitation in nursing homes. Previous studies have examined rates of abuse in nursing facilities, direct service worker capacity issues, and compliance of states to maintain nurse aide registries. This study looks across all of these issues, by examining the process states go through to collect and maintain information in their registries, state and employer mandated background check procedures, reporting and investigating policies/practices when abuse allegations are made, and the impact of such processes on the direct service workforce, employers and state agencies
Client Area: Federal Government
Expertise Area: Aging and Disability
April 2006
North Carolina Department of Health and Human Services
Lewin contact: Lisa Alecxih
North Carolina offers an array of long term care (LTC) services for Medicaid beneficiaries. In 2004, House Bill 1414 directed the state’s Depart.ment of Health and Human Services to commission a study of whether an institutional bias exists in Medicaid-financed LTC services. In 2001, North Carolina’s Institute of Medicine presented a General Assembly-commissioned report entitled “A Long Term Care Plan for North Carolina.” The report outlined barriers in state LTC policy and practices and offered recommendations to the State on how to improve the LTC delivery system. This study builds on those findings and recommendations and offers an updated look at North Carolina’s Medicaid LTC system
Client Area: State and Local Governments
Expertise Area: Aging and Disability
April 2006
Pennsylvania Health Care Association
The Pennsylvania Health care Association commissioned The Lewin Group to conduct a study that would help answer the following questions:
What long-term care services will be needed and available over the next ten years?
What is the current supply of long-term care services in the Commonwealth?
What will the demand for long-term care services in the Commonwealth be over the next 10 years?
Given the current supply of long-term care services and the estimated rate of growth in the demand for these services, what are the trade-offs between providing nursing home care versus providing home- and community-based services?
This report is the second in a series of reports commissioned by the Pennsylvania Health Care Association. The first report provides information on the economic impact of nursing homes on the Commonwealth.
Client Area: Associations
Expertise Area: Aging and Disability
February 2006
Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities
Lewin contact Lisa Chimento
The Delaware Governor's Commission on Community-Based Alternatives for Individuals with Disabilities commissioned The Lewin Group to review and analyze the challenges and opportunities the State may face when undertaking a Money Follows the Person or “rebalancing” initiative. In essence, the study seeks to evaluate the manner in which Medicaid recipients access Medicaid benefits—either in institutions or in the community—and whether there exist policies or procedures that favor institutional placement over home and community-based services. It also reviews State initiatives on rebalancing and models the potential financial impact of Delaware’s adoption of a Money Follows the Person program.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
May 2005
Indiana Family and Social Services Administration
Lewin contact: Joel Menges
The Indiana Division of Disabilities, Aging, and Rehabilitative Services and the Office of Medicaid Policy and Planning contracted with The Lewin Group to study the impact of Senate Enrolled Act (SEA) 493, which makes significant changes in the State’s long term care (LTC) programs for individuals of advanced age and persons with disabilities. The study focused on the impact of changes to the State’s Section 1915(c) Aged and Disabled Medicaid Home and Community-Based Services Waiver.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
March 2005
Pennsylvania Health Care Association (PHCA)
Continued increases in longevity among the U.S. population, including those with chronic diseases or disabilities, are creating a demand for more LTC services of all types. Pennsylvania currently ranks second among the fifty states in the proportion of residents aged 65 and over. The Commonwealth’s fastest growing age group includes those aged 85 and over. Although occupancy levels in Pennsylvania nursing facilities have declined somewhat over the last few years, the rapidly growing aged 85 and over population necessitates a critical appraisal of the population's need for LTC services in the future and how these services should be coordinated. This appraisal has important implications for the Commonwealth's economy as well as the LTC community. With the current policy emphasis on HCBS LTC services, and the use of various provider taxes and intergovernmental transfers which may not be sustainable, there is a growing concern over the future financial viability of nursing homes. As such, various economic and healthcare delivery scenarios must be considered in future planning in order to assure an adequate supply of all types of LTC services to meet the complex needs of an aging population.
Given these concerns, PHCA commissioned The Lewin Group, Inc. to conduct a study that would address two basic questions:
What is the current economic impact of the nursing facility community on the Commonwealth?
What LTC services will be needed and available over the next ten years?
This report address the first of these two questions and contains information on the economic impact of nursing homes on the Commonwealth of Pennsylvania.
Client Area: Associations
Expertise Area: Aging and Disability
July 2003
Wisconsin Legislative Audit Bureau
Lewin contact: Lisa Alecxih
The Lewin Group concluded its three year study of a managed long term care experiment in Wisconsin with the final of four reports summmarizing the implementation of the program and analyses of the initial access, cost and quality outcomes. The Family Care program combines county-run aging and disability resource centers to provide centralized outreach, information, referral and intake, with capitated care management organizations to coordinate the delivery of and payment for services. Unique features of the program include: a single point of entry for three target populations -- older frail adults, non-elderly adults with physical disabilities, and adults with developmental disabilities; a risk-adjusted capitated payment system for Medicaid long term care services; the institution of interdisciplinary care management teams that, in addition to long-term care, consider acute and primary care needs and strive to balance consumer preference and cost; and development of a quality assurance and improvement system that improves upon the traditional process measures by seeking direct input from members.
Our independent study conducted for the Wisconsin Legislative Audit Bureau concluded that:
The program substantially met the goals of: 1) increasing choice with a broader range of providers, more residential alternatives, and the option for members to direct their own care; 2) expanding access by eliminating waiting lists for services in the five counties piloting the full program; and 3) improving quality through a focus on social outcomes.
The program has yet to demonstrate improved quality related to an individual's health using claims-based measures, in part due to the time period of our analyses, and the need for more time to fulfill the promise of better care management.
Despite the potential for the capitated rate to inhibit spending, existing enrollees did not experience a decline in service levels during the first year of the program.
It is too early to draw conclusions regarding the program's ability to create a cost-effective system for the future. Early evidence indicated that the Family Care counties had increases in spending similar to comparison areas and that spending on new enrollees offset savings associated with lower per capita spending increases and reduced use of institutions.
The Wisconsin experience can provide valuable lessons related to single entry points, infrastructure, governance, information technology, care management, service integration, provider development, consumer direction and quality assurance/improvement for other states considering changes to their long term care systems.
Expertise Area: Aging and Disability
February 2003
University of Maryland, Baltimore County
The home and community-based Medicaid waiver that serves seniors in Maryland requires restructuring, in order to make services available to eligible seniors on a more expedited basis. In our report, we researched this waiver, known as the "Older Adults Waiver," and we made several recommendations to make the it more efficient. These recommendations include a sequence to develop a single point of entry, as well as tools to recruit, retain and pay providers, to ensure capacity in the community.
Client Area: State and Local Governments
Expertise Area: Aging and Disability, Medicaid and CHIP
January 2003
American Health Care Association
This study updates an earlier report by The Lewin Group released in March 2002. This study update provides the impact of Medicare and Medicaid payment shortfalls on nursing facilities in 2003 and 2004.
Client Area: Associations
Expertise Area: Aging and Disability
December 2002
DHHS, Administration on Aging
Intended for the staff of State Units on Aging, Area Agencies on Aging, Indian Tribal Organizations, and service providers, this Resource Guide offers practical information to help implement the new National Family Caregiver Support Program (NFCSP). As a Resource Guide—not a handbook of program policies or prescribed procedures—it features examples and resources to stimulate members of the aging network to pursue approaches that afford caregivers flexibility and assistance in meeting caregiver service needs. The information is based on established research and early practice experience and covers: roles of the aging network, profile of family caregivers, systems development, program effectiveness, working with families and other caregivers, NFCSP service components, designing the NFCSP in the context of diverse caregiver populations, and nontraditional approaches.
Client Area: Federal Government
Expertise Area: Aging and Disability
November 2002
Wisconsin Legislative Audit Bureau
Lewin contact: Lisa Alecxih
This third implementation report for the Wisconsin Legislative Audit Bureau regarding the Family Care program serves as an update to The Lewin Group's August 2001 report. It notes the progress made in implementing the Family Care model in the pilot counties, as well as issues the State and the counties will need to address as program expansion is considered.
Client Area: State and Local Governments
Expertise Area: Aging and Disability
April 2002
DHHS, Centers for Medicare and Medicaid Services
Lewin contact: Lisa Alecxih
As part of a CMS-funded study, case studies were conducted in Alabama, Indiana, Washington, Wisconsin, Maryland, Michigan, and Kentucky to assess the major features of the home and community-based services system for older people and younger adults with physical disabilities in each State. The case studies analyzed the financing of services; administrative systems; eligibility, assessment, and case management structures; the services provided, including consumer-directed home care and group residential care; cost-containment efforts; and quality assurance. The role that Medicaid plays in home and community-based services is a major focus of the study.
Client Area: Federal Government
Expertise Area: Aging and Disability, Medicaid and CHIP
February 2002
AARP Public Policy Institute
Lewin contact: Lisa Alecxih
For an AARP Public Policy Institute issue paper, Long-Term Care Insurance: An Assessment of States' Capacity to Review and Regulate Rates, The Lewin Group conducted a survey of state insurance departments' current practices relating to the regulation of long-term care insurance rates and assessed their ability to effectively regulate premiums for the long-term care insurance market. Several reports in the last decade question the adequacy of state regulatory efforts, citing insufficient regulatory efforts to protect consumers and chronic shortages of staff and resources. In addition, large increases in rates by some companies raise concerns about state efforts to ensure accurate pricing for long-term care insurance. Large rate increases, or a series of rate increases over time, could: (1) threaten consumers' ability to continue paying for coverage; and (2) erode confidence in the products being offered by the industry. The paper presents findings from the survey and ratings of states' current pricing review practices, as well as recommendations.
Client Area: Associations
Expertise Area: Aging and Disability
August 2001
Wisconsin Legislative Audit Bureau
Lewin contact: Lisa Alecxih
In its second report for the Wisconsin Legislative Audit Bureau regarding the Family Care program, the Lewin Group notes that since its first report in November 2000, the Department of Health and Family Services and the pilot counties made considerable progress in implementing Family Care. Based on information through June 2001, the pilot counties demonstrated different stages of program processes, capacity, and enrollment. In January 2002, the counties will implement a final program element, an independent enrollment broker, as proposed by the Department and approved by the federal government. The report points out a number of areas that need to be addressed as the pilots continue, including outreach, provider relations, care management, quality assurance, and cost.
Client Area: State and Local Governments
Expertise Area: Aging and Disability
January 2001
DHHS, Administration on Aging
Lewin contact: Lisa Alecxih
This issue brief, supported by the Adminstration on Aging, examines caregivers providing regular assistance to individuals with a disability or long-term health problem of all ages in 1998. It is intended to provide the Aging Network with general socio-demographic information about its potential target populations as a background for designing and implementing caregiver support services around the National Family Caregiver Support Program.
Client Area: Federal Government
Expertise Area: Aging and Disability
December 2000
DHHS, Centers for Medicare and Medicaid Services (CMS)
Lewin contact: Lisa Alecxih
The Centers for Medicare and Medicaid Services contracted with The Lewin Group, and its subcontractors, the Urban Institute, the University of Minnesota, Mathematica Policy Research, Inc., and the MEDSTAT Group, to design and implement a study of the impact of Medicaid home and community based services programs on quality of life, quality of care, utilization and cost. The research project is studying the financing and delivery of services to older and younger people with disabilities in seven states and the Medicaid financing and delivery of services for individuals with mental retardation and developmental disabilities (MR/DD) in six states.
Client Area: Federal Government
Expertise Area: Aging and Disability, Medicaid and CHIP
November 2000
Wisconsin Legislative Audit Bureau
Family Care is an innovative, system redesign experiment designed to improve Wisconsin?s long-term care (LTC) system. Family Care creates two new community organizations, a Resource Center (RC) to provide one-stop shopping for information and assistance in obtaining services, and a Care Management Organization (CMO) to help arrange and manage services. The program also introduces managed care principles to control escalating costs. If the program achieves its goals, the new long-term care system will provide elderly and adult individuals with physical or developmental disabilities with greater access to flexible services that promote independence and facilitate a higher quality of life.
The Wisconsin Legislative Audit Bureau contracted with The Lewin Group to evaluate the Family Care pilot program. This report completes the first stage of the project, which was a process evaluation. The second stage will be the development of an impact evaluation, which will assess the extent to which the pilot projects are meeting the stated goals of Family Care. The final stage of the evaluation will assess the benefits and costs of the program This report contains background information on the Family Care program as a whole, as well as evaluative information on the development of each pilot project. The report also contains a glossary of terms and a research methodology section that demonstrates the contacts made in the five pilot counties?Fond du Lac, La Crosse, Milwaukee, Portage and Richland?in order to assess the current status of the Family Care program.
Client Area: State and Local Governments
Expertise Area: Aging and Disability
June 2000
DHHS, Office of the Assistant Secretary for Planning and Evaluation (ASPE)
Lewin contact: Lisa Alecxih
This report presents findings from a survey of employers offering long term care (LTC) insurance to their employees. The survey found that the employer LTC insurance market provides greater access to coverage than the individual LTC insurance market by providing opportunities to avoid extensive medical underwriting. Employers identified simplicity of plan design (most importantly, limiting the number of choices employees face) and employee education as factors critical to the success of a LTC insurance offering.
Client Area: Federal Government
Expertise Area: Aging and Disability
June 2000
DHHS, Health Care Financing Administration (HCFA)
Lewin contact: Lisa Alecxih
This report reviews literature and provides a brief summary of current program statistics for the Medicaid 1915(c) Home and Community-Based Services (HCBS) Waiver program. The review is limited to literature specifically related to the 1915(c) waiver program and focuses on two categories of programs that constitute the majority of recipients and expenditures: programs serving aged individuals and individuals under age 65 with physical disabilities (A/D); and programs serving individuals with mental retardation or developmental disabilities (MR/DD).
The document addresses the following six areas:
History of the waiver program;
Current program characteristics;
The role of care management and consumer direction;
Issues related to quality of care and life in HCBS waivers;
Cost control mechanisms; and
Evaluations of cost savings associated with the waiver program.
Client Area: Federal Government
Expertise Area: Aging and Disability, Medicaid and CHIP
March 1998
National Association for Home Care
Lewin contact: Lisa Alecxih
The Medicare Home Health Interim Payment System (IPS) raises concerns for beneficiaries and providers. A temporary plan proposed until HCFA develops a home care PPS, the IPS may cause the number of home health agencies (HHAs) exceeding the Medicare cost limits to more than double and the published cost limits to decrease 21% on average overall. HHAs may operate without knowing the per-beneficiary limits for up to 6 months of the initial IPS cost reporting period. Strategies developed by HHAs to cope with this reduction may include increasing the proportion of low-end users with fewer visits and restraining costs per visit and number of visits per beneficiary. Some of these strategies could have considerable consequences for high-use home health clients.
Client Area: Associations
Expertise Area: Aging and Disability, Medicare
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