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Presenter: Terence Ng, Center for Personal Assistance Services

February 10th, 2010

Lewis Kraus: Welcome to the Center for Personal Assistance Services webinar. I am Lewis Kraus. Today's presentation, Medicare and Medicaid in long term care, is the third in a series of webinars hosted by the center that will focus on issues around all aspects of personal assistance services.

First a little information on how this webinar and its software work. The webinar will be audio with slides. For those of you who want or need captions to support the audio, you can select the CC button at the top of your screen. If you prefer to listen by phone, use the telephone hand set button in the audio window and you will connect to the teleconference or dial the number and pass code given.

The presentation will take about 30 minutes and then we will open the floor to questions at about 15 minutes before the hour.

If you are using the computer audio, please uncheck your audio. That is the microphone button at the bottom left of your window. It should be gray, not yellow. Nobody is on yellow now so no need to check it. Because of the size of the group, we are going to only take written questions. You can write to us in the chat window on the left hand side of your screen. It will probably be best to send the message to moderator. So where it says send to, pull down to where it says, "moderators ."

If you have an issue during the talk, send the message to me or to moderators through that chat window. When there is question time, send those to that chat window as well. The Center for Personal Assistance Services is funded by the National Institute on Disability & Rehabilitation Research and the U.S. Department of Education. It's a five year research and training center at the University of California, San Francisco. The first center was established in 2003. The current funding cycle began in fall of 2008. The goal of the PAS center is to improve the access, quality and costs of PAS for people with disabilities to live independently, comfortably and safely in the community and to participate in society, including employment.

The center is conducting research in the following five areas. The need for personal assistant services, home and community based services, workers and caregivers, or the PAS workforce, economics and workplace PAS and emergency preparedness.

The Center has several major collaborators. The center is based at the University of California, San Francisco and Charlene Harrington is the principal investigator. Other collaborators are the center on disability at the public health Institute based in Oakland, California, The Topeka Independent Living Resource Center in Topeka, Kansas. PHI, formerly known as the Paraprofessional Healthcare Institute in New York. The research Triangle Institute based in Washington, D.C. And the Burton Blatt Institute in Syracuse, New York, and Washington, D.C.

For those of you who are trying to select your video window, there's no video we will be showing so no there's no need to click on any of the video windows.

Today's talk is being given by Terence Ng from the University of California, San Francisco. Terence is a research analyst in the Department of Social and behavioral sciences at UCSF.

He has collected data and conducted analysis of home and community based services. Most recently he has worked on studies of state Medicaid programs where he is tracking personal assistance services, home and community based waivers and home health activities across all states along with state PAS activities and policies. He has co authored a number of articles on personal care and home and community based waivers.

Terence, I am now going to turn it over to you and you can go ahead and begin.

Terence Ng:Thank you, Lewis.

Good morning, good afternoon and good evening, everyone. This is Terence coming to you from San Francisco and I wish Lewis had chosen a better picture of me, but that's a rough indication of how I look like sitting at my desk. The title of this is the Medicare and Medicaid in long term care.

It's a rather expansive title chosen by health affairs and I hope everyone has done their homework and at least gone through the health affairs article, but if not, we will try to explain as much as it here as possible.

One more thing, if anyone for whatever reason can't hear me well enough or I am speaking too softly or too fast, you could just write out onto the chat window and I should be able to respond.

So go to the next slide.

We will see as titled this is total long term care spending in the United States in the latest year that we have, which is 2007. And why we think this is important is when we look at the share of payment by Medicare and Medicaid, and we can see that it's close to 70%. And when that's the case, it's more than $100 billion a year. So that is why we think that's important to look at and we want to concentrate - even though this is a talk on both Medicare and Medicaid, we are going to concentrate quite a bit more on Medicaid because Medicaid pays quite a bit more as we can see from this chart.

Look at the next slide, a wordy slide, but we will look first at Medicare Long term care. There are three kinds. And most of you could see this, the first one is the short term post acute care. What we mean by short term, it's equal to or less than 90 days after hospitalization. And these are provided in nursing homes or at home by home health agencies. There's also hospice care. And there's other regular Medicare services, such as acute care, medical care and other services that we do not look at here. Eligibility for short term nursing home and home health periods is the need for skilled care or therapy for a short period of time, as I mentioned which is 90 days or less. After the 90 days after the Medicare benefits with exhausted, anyone who would required continued services would need to either pay for them out of pocket, or if they have long term care insurance, insurance would pay for them, hopefully. And for those who are eligible in their state, Medicaid would pick up the tab.

Next slide.

We then looked at some of the trends that we can see for Medicaid/Medicare home health and nursing home users. We excluded hospice care from here because that's sort of an end of life care and we sort of wanted to concentrate more on the 90 day short term care that Medicare provides. And here, we have an abbreviated chart, or graph, from 1999 to 2007. And when we concentrate on the latest year, 2007, we can see that-- well, we can't see, but there is there were 32 million Medicare participants in 2007. What we can see is out of that 32 million, 4.9 million or close to 5 million were utilizing home health and nursing home services. That's about 15% of total Medicare beneficiaries. The number of beneficiaries grew between 99 and 2007. Home health and nursing facility beneficiaries grew by about 21%. That's from about 4 million to about 5 million. This happened as the general Medicare program participants grew by about 10%. So we could see the growth in these long term care services, short term, even though it's only within 90 days, that still has outgrown the general growth in Medicare. We also can see that the Medicare nursing facility users, the one in red, grew by 32% over the study period. There are a bit less than 2 million nursing home users in 2007, while there are about 63% or 3 million home health users in 2007.

We then look at the expenditures, which is the next slide. We can see the difference in a sense that even though in the previous slide, we saw the red colored bar in 2007 is only 37% -- nursing facilities is only --37% of nursing facilities participants made up 37% of total long term care; but expenditures was almost 60% for nursing homes. Of course that includes room and board and everything else. But I think we can see that there is a quite a bit more spending on nursing facilities, as compared to home health, even though quite a bit less people are in Medicare nursing homes. So home health grew by 59% over the period, while expenditures overall, grew by 75%. This sort of shows the really vast extra demand for Medicare dollars among long term care persons compared to the general Medicare program. When we look at the next slide, here we have a summary of really what we just talked about, which is that Medicare over the years is paying a growing proportion of total nursing home expenditures. This has increased from 23% in the beginning of our study period, 1999 to 32% of total nursing home expenditures in 2007. When we say total nursing home expenditures, that includes private pay, long term care insurance pay, Medicare and Medicaid. So out of all these, Medicare pays 32%. That's only for nursing homes. The proportion paid for home health is about the same. So there hasn't been much higher demand for home health over the study period.

Look at the next slide, and you can see that we have gone sort of into Medicaid long term care. Most people would know what Medicaid is and what it provides. But just a brief look through, which is that Medicaid is a joint federal state program jointly paid for by the state and the federal government. Remember the very first slide, it's a primary payer for long term care services. About 42% of all long term care in United States are paid for by Medicaid, and when we look at eligibility, there are couple of different - they're really, really complicated - but general groups of people who are eligible, first are those who are automatically eligible who called categorically needy. They have to receive the SSI program money. And then we have a couple of other states, 35 all together, including D.C., who have the medically needy program and that allows people to spend down by incurring their medical costs and then meeting the state's requirements for eligibility for Medicaid. One more thing about Medicaid long term care is that just like Medicare long term care, nursing home care and home health are mandatory benefits. However, the difference of Medicaid long term care is that they are optional services that can be provided in the home and community. And then we will talk about that a bit later on.

Move to the next slide.

Sort of a general trend analysis is that long term care is about a third of total Medicaid spending. This has not changed over the study period. So it's about 32 33%. However, nursing home growth in expenditures and population within Medicaid has not kept pace with the growth in the aged population. What do I mean by this? There has been no change when we look between 1999 and 2007 there has not been a change in terms of growth rate

[Background noise]

[Talking in background]

Terence Ng: I am hearing people call in.

Terence Ng: Now, there's music. Okay.

So there's been no change in nursing home use among Medicaid. We will Look at that a bit further on, but we can see the demand for nursing home use among people aged 65 and over has gone up. Between the year 2000 and 2007 there was a growth of 17% in the aged population for age 65 and above and 30% in growth in terms of people aged 75 and above all this happened as no change in nursing home use. What trying to say here is that there is even as people age there's no extra demand for nursing home beds. We can see also that 40% of Medicaid institutional users consume 61% of total expenditures in 2006. That would include room and board and other costs.

Look at the next slide. We will concentrate on Medicaid home and community based services. Basically there are 3 that we will look at here. One is the state planned personal care benefits. There are 31 active in 2007. Why they are active is because there are actually 33 who have them on their books. It's part of their regulations and law, but two states actually do not enroll anyone. So that's why we call them active only in 31 states. That is in 2007. There seems to be a trend of expansion of Medicaid state planned personal care services, and we saw about 32 active states by 2008.

Again for Medicaid state planned personal care services, as long as the state allows them and provides for them, it must be statewide and it's available to all Medicaid eligible persons.

Let's skip down to home health. Because I want to talk about the mandatory service as well. It's the same eligibility criteria for home health as is for personal care, because as long as you have Medicaid, you can have home health; but as long as you are eligible for Medicaid institutional care, because it's supposed to be a substitute for institutional care.

On the other hand there's the big behemoth of HCBS services which is the waiver program. In 2006, 2007, there were about 270 different waiver programs in - I was going to say all states, but no essentially 49 states, I'm sorry, 48 states plus D.C. We call them 49. It's a very big program, as we shall see a bit later on. In terms of eligibility wise, it's people who want to get on it, must be nursing home eligible. Almost just like the home health participants. But they are selected really by the states and when states set up these waiver services, they have the option of serving some people and not serving some people so that's why it's a waiver. They can waive state wideness, and they can waive the ability the requirement of serving all Medicaid eligibles. So again there are other cost caps and other kinds of caps that states can put on these waiver services, such as geographic limits, they can cap the amount spent per person, they can cap the amount spent overall and also establish waiting lists. And we have seen waiting lists stretching into years and decades for such waiver programs. And these people might be either trying to live at home on their own, or in nursing homes wanting to get out. And so waiver programs are sort of services provided to people at home so that they can maybe get out of institutions or at least prevent them from getting into institutions.

Go to the next slide.

And this really is how much Medicaid home and community based services, HCBS, has been grown over the study period. Our latest year, if you realize, is a bit different from the Medicare years. This is up to 2006. Because there's a bit of a lag between what states report. And Medicare is a federal program, so they have a bit more updated program; while Medicaid is administered by states so they are able to lag a bit longer so our latest year is 2006. The most important thing here is we can see that the yellow and the, let's see, gray, which is home health and personal care, the number of people served are about the same. By waivers, they take up 40% or so of the close to 3 million HCBS participants in 2006.

From 1999 to 2006, 51% growth from 1.9 mill to 2.9 mill. So it's quite a bit a change and addition to the roles of the Medicaid HCBS participation.

We look then at HCBS expenditures, which is on the next slide, and if you remember I just mentioned participant growth was 51% here, expenditure growth was 122% from 17 billion to 38 billion, so it more than doubled. 38 billion in expenditures, if you remember our home health and personal care, the yellow and gray, was about equal in terms of participation. But here we can see that personal care spent double than that on home health. And the green part, the waivers, spent a huge percent of the total HCBS expenditures.

Look at the next slide. Here we try to explain why this is happening.

We can see that there are a couple of surveys out that shows a growing demand by people to stay in their homes rather, hand institutions and this is exemplified by a case that, I think, many of you might have heard of, is the Olmstead case in 1999 where the Supreme Court says that individuals do have a right to stay in the home and community if they are able to do so. And the government cannot, through the health programs, force people to stay in institutions. So that's one of the driving forces of HCBS growth. And because of this, what we call Olmstead ruling, states have been hit by a variety of lawsuits. And they have decided to expand their Medicaid HCBS after these lawsuits, either through established, getting rid of waiting lists, establishing new waivers, or as a long term planning tool, the establishment of what they call an Olmstead plan. The Federal Government that's on the state level, while on the other hand the Federal Government, through CMS, has provided quite a number of initiatives to help states to comply with the Olmstead decision. There are a couple of programs, such as, money follows the person, a demonstration programs. The new DRA programs that are trying to assist states to transition people to HCBS within Medicaid. But even with all these, the average spending per person for Medicaid HCBS is about $13,300 in 2006. We compare that in the same year, an average person in an institution will cost Medicaid about $33,000. So it's about 3 times as much in an institution compared to being served at home.

Then we look at the next slide and we can see that this is a slide where we segregate the persons within the largest programs of HCBS, which is the 1915(c) waiver. We separate them out into four distinct groups, by target group we call them. MR/DD, mentally retarded developmentally disabled. The aged and disabled persons, the disabled persons, so non aged disabled and then we have others who are people with HIV/AIDS, mental health issues, traumatic brain injuries and what not. This is for 2006. We can see a huge majority, about 90% when we add the yellow and green chart up on the left hand side, that makes up 90% of all participants in waivers. So that aged disabled and MR/DD.

Then, we look on the left hand side, which is that even though MR/DD makes up only 40% of participants on the left, they take 72% of all expenditures as we can see on the right. On the other hand, disabled, make up half of all persons, but spend less than a quarter of Medicaid expenditures. So this is a chart that we wanted to show. And we can see that when we look at the expenditures for participants for MR/DD, which is divide 18.1 billion by 400 plus thousand, it's about $41,000 per person. So spent $41,000 per person, but when we look at aged disabled the exact same figure, it's less than $10,000 spent per person. So there's quite a bit of discrepancy. Obviously there's a high acuity level among MR/DD, but what trying to show here is a quite a bit difference between spending by target groups even within the same program.

Look at the next slide, we have been talking all about the raw data. But some people would ask, when we look at the national data, we have to adjust it by population. That's what we try to do here. The United States overall, on average, they are about 9.6 persons on Medicaid HCBS for every 1,000 persons; that's in the United States. So close to 10 persons per 1,000 uses HCBS in Medicaid in 2006. The darker colored states are those with more participation and the lighter colors are those with less participation. I had a top three, bottom three here; just the top really, which is the state of Iowa, somewhere; it's close to 17 persons per 1,000 state population in Iowa. Then we look at the least participation, we have Virginia which is about 3.2 persons per state population. So this chart is sort of an indication of how willing states are willing to provide HCBS to their Medicaid participants.

We look at the next slide, and it's essentially the same slide, but for expenditures. This is expenditures that readjusted for population and what this U.S. map will show is really the states that are willing to spend money once people are enrolled, how much money are the states willing to spend on these people? And this slide tends to show them. We have states such as Texas, a huge state, even though if you remember it wasn't a light colored state in the previous slide, but it's a light colored state here. That means that even though they enroll people within their Medicaid HCBS program, they are not spending, at least as much as other states on these people.

Again, we have the top and bottom, the top is on the right hand side, and that's New York, $384 per capita, which is per state population. And we compare that to Vermont, which is only $42 per state population. And that's quite a big difference. Almost a ten times difference between the two, top and bottom states.

We then move on to the next slide. After looking through all the data and numbers and colors, a bit more of policies. We at the Center for Personal Assistance Services, we conduct an annual policy survey for the home health state plan personal care and the Medicaid HCBS waivers. And so this couple of next slides are sort of an overview of what we have found. In terms of policy wise what states can do-- remember, this is Medicaid so states with can have their own policies for each individual program. For home health and personal care, they can be cost caps, they can be service caps. So amount of services, the amount of money that can be spent, but there's no wait list. All eligibles must be served. When we look only at the waivers, where we say financial and functional eligibility can vary, we mean that states can have different criteria for different waivers. And in between states the criteria also varies. There are also cost caps and service caps. There's also a limit on the number of people who can be served and that is established even before they know what the demand is. So it's really based on the amount of money that the state will have. So they have a slot system. And the main difference with waivers is they can establish wait lists.

Many states will use a combination of expenditure ceilings, service limits, hourly limits as well as geographic limits for waivers. Geographic limits is usually limited to a particular county, particular city or a few cities or a few counties. And anyone outside of that is out of luck.

Look at the next slide.

As you remember we were talking about the main difference between waivers and other programs is the establishment of slots and waiting lists and here we can see the main by target group, which is MR/DD, aged disabled and what not, the total number in the United States of slots, which is 1.4 million, and that is divided really between 95% of that is divided between the aged and disabled and MR/DD. They get slots within the waiver programs. However, when we look at the even though they are slots it's not necessarily that these people can then get into programs. Because there's still an almost 400,000 person waiting list in the whole United States. Again, and we can see that MR/DD takes up most of the people who are waiting for a slot. Waiting for a place in a state waiver program. What we need to remember is that this is a national average; national total. So a state with excess capacity in their waiver program will not have waiting lists obviously, hopefully, but there might be a neighboring state who does not have enough slots and they have a huge waiting list and that will factor into this national total.

Then when we look at the average length of time, we don't have a number here, or a chart here, but the average length of time an individual spends on a waiting list for an aged waiver, it's about 9 months. For a MR/DD waiver, it's about 32 months. What is that? 2 1/2 years probably? That's quite a while, in terms of waiting for HCBS services. Remember that most people have been approved for Medicaid services. So these people might already be receiving Medicaid services at home or they might be in an institution waiting to get out of them.

Look at the next slide. We look at the overall picture. As percentage of total long term care, in 2006. Again, we have the dark colored states, mostly on the left; the left coast. And we have a lot of states with the higher the number, the more persons served in HCBS as a percentage of total long term care in that state. On average in the U.S., about 61% of persons in long term care are served in Medicaid HCBS. That's the national average. Again, we have the top and bottom if anyone is interested, is Alaska, gets 87% of their long term care participants are served in Medicaid HCBS. And Indiana is the bottom with only 30%.

Then we look at expenditures in the next slide. We can see that instead of 61% spending, it's actually only 39% spending. So in terms of Medicaid HCBS expenditures, as percentage of total long term care only 39% is spent on Medicaid HCBS. But again, we have the left coast, with mostly dark brown, which is the most percentage. And we have Oregon as the winner with 68% of the total long term care expenditures being spent on Medicaid HCBS. And we have Mississippi with 12% of their expenditures being spent on Medicaid HCBS. Now, we move on to sort of a really the discussion phase of our no yes. Complexity and fragmentation of HCBS programs would be the title.

Yes.

Here we can see that why we call this complex, a very complex program, is because of the sheer amount of choices that they task to provide HCBS. And these I won't read them out, but these are most, if not all, of the programs that CMS provides in terms of choices that states can enroll. All these are okay from the point of the Government. But at the end of the day, it's costly and confusing to consumers because many states, even within states, they have very different administration and eligibility determination, structure and persons to speak to. You get the runaround when you call one department and they say it's someone else who should be doing this. When you have things like that, we have consumers who may just give up or not able to navigate to the system and they fall into the cracks and go into the mandatory program, which is the nursing homes, even though they might be eligible for HCBS. So the net effect of costly and confusing program, really is institutionalization. Here when go to the next slide, what the paper sort of calls for is a more integrated coordination of funding between Medicare and Medicaid and we have to start from hospitals, because that's where most of the Medicare long term care patients come from. Right after discharge they go into Medicare, home health or nursing homes. If there's no appropriate long term services that can be arranged, these people just by default goes into nursing homes. And when you go into a Medicare nursing home, if you are eligible for Medicaid, after 90 days, you are probably just going to continue on because, you know, a lot of times these people do not have the resources or ability to go back out into the community. That's a serious problem for Medicare, because a lot of these people then also go into the hospital. So there's a great need to have really effective discharge planning and post hospitalization follow up programs, especially for Medicare patients.

We go to the next slide.

The next couple slides really is the general discussion that is in the paper. I will do a quick go through. We have sort of spoken of all these previously, but we have the growth in Medicare; that's due to growing demand for rehabilitation. We have the rapid increase in Medicaid HCBS. We have wide interstate variation in usage, both interstate and intrastate between target groups as well. So there's also large waiting lists and that really shows both unmet need and inequalities between target groups and between states, just in terms of how much states are willing to spend on one group compared to the other. We also see that even though HCBS spending has grown that much over the study period, it's still below institutional spending.

And we have to address what is called the Woodwork Effect. That is what states have really thrown up as the barrier as a reason for not expanding HCBS as rapidly as they can because they feel that if we expand HCBS, people who would not want to be in an institution in the first place, would be more than willing to get the services provided within HCBS, because then they will not be in institutions. But we have found that well established HCBS programs has less overall long term care spending, versus those with low HCBS spending. I'm sorry we should moved our slide.

To this general discussion No. 3.

To wrap up, we have found that the current budget crisis, that's throwing up a lot more barriers in terms of cost caps, in terms of limits, and that is going to impact the growth of optional HCBS. This is even as Medicaid enrollment grows as people get more eligible fall into that eligibility category, and as the population ages. So we feel that there's a need for structural reform of the long term care system to sort of try to expand Medicaid - to try to expand HCBS, through really better coordination between Medicare and Medicaid. That's the end of my portion, at least. I am giving it back to Lewis.

Terence Ng: One thing is that if there are any questions, please let me know and we will discuss that.

Lewis Kraus: Thank you very much, Terence that was a great presentation. And I want to invite people to ask their questions now in the chat window. And I will share it with everyone. We will ask read them off it Terence for him to answer. I want to answer one thing that is important for you about people who have been asking about the slides. They are on the website. On the Center for Personal Assistance Services website at http://www.pascenter.org and you will see the link on left hand side for web task and if you go in there, you will see Terence's presentation, listed and a link for the slides.

Let's take our first question here, Terence, and that will be from Renate. Is the data you presented available at the state level?

Terence Ng: I'm sure I get what you mean when you say presented available at the state level. Yes, I think I got what you mean, which is that all the individual program data is available at the state level and we do collect them at the state level, especially for the Medicaid program because the most reliable data is from the state themselves. More importantly, all our data is aggregated for United States, but they come from state levels.

Lewis Kraus: The next question from Althea is: Does your research support alter CMS policy to make HCBS an entitlement as fiscally sound?

Terence Ng: As fiscally sound? To make HCBS entitlements as fiscally sound - as I'm not sure what, but I think part of my research, our research, does support the argument that HCBS should be entitlement. And there is a follow up research to this particular research as a fiscally sound policy.

Again, to say, to get hold on to make it an entitlement, the fact it's an optional program and states are able to not provide it while they have to provide nursing homes as a mandatory program, will it be as expensive as they are? We think that making, or expanding at least expanding HCBS to as many people as possible we will be able to bring down the overall long term care costs of states and of the federal government's share of the long term care expenditures. There are also follow up studies of this particular study that shows that it's approximately even if we include SSI and S.S.P payments and other kinds of payments that states provide to persons living at home who are eligible, together with Medicaid HCBS programs to keep them at home, the states will still save approximately $57,000 per person, versus a person who the state pays to keep in a nursing home. So I think if we do make an entitlement, in the first couple of years, we may see an increase in long term care costs, but I think as we look down through the decades, we will see, you know, a much slighter increase in long term care costs, versus continuing making continuing just emphasizing nursing homes as our main source of long term care.

Lewis Kraus: Okay and reading down the next question: Renate had a follow up about could she do a similar analysis for her state and can you help direct me to the data. What I will say here and I emailed to her, you can just go ahead and contact Terence by email for further guidance.

The next question, Dana, asks the dollar amounts you talked about are not on your slides. Is it possible to get a written interest transcript of your presentation? What I will say about that Dana is that the captioning is -- this entire presentation is recorded and will be on the website at the webcast link. If you want to you can even re-see the captioning as well and the transcript of this session will be on that caption, based on that caption. So the data that Terence presented will be available on that.

Next? Diane. Sorry.

This is to somebody else.

Bill Asks: Given the potential savings posed by waivers and SPO do you think the federal government will increase its incentives to states to encourage its use as a potential savings compared to institutional care?

Terence Ng: What I think is the federal government has done many things to try to encourage states to increase use of HCBS programs one of the main - a new initiatives in 2005, that really sort of was a push and that sort of increased the number of demonstration programs to get states to try out different ways of providing HCBS services. There a quite a number of states now, Rhode Island, Vermont and Arizona, some of you are from that state, who are moving into what they are calling global commitment waivers or what not, these are the demonstrations allowed by the Federal Government, the 1115 waivers, where states are able to sort of try out different methods or what they think is unique to their states to be able to try to move people out of institutions, serve as many people as possible in HCBS, and at the same time, get the economies of scale required to save much as money as possible on both the state and federal level. So yes, I do think that the Federal Government has done quite a good job in trying to promote HCBS, but I think one of things we're trying to say is that it's getting a bit too complex and there's too many small little different programs out there that it might be a good idea for the Federal Government to sort of consolidate them into a more understandable program, at least for consumers.

Lewis Kraus: Okay. And I want to just mention that we have it's about 3 minutes before the hour.

We had said we will go up until the hour. And I want to take care of a couple of housekeeping things on the page is the address of the website for feedback. I want to make sure that you are able to do that. If you in case we lose you as we answer more questions. I am going to try and put that in up for you right now so you will be able to link to it directly through this website. And let me just type it in there. One second. And if you can answer that, that would be help us as we continue on answering the questions.

The next question is from Diane.

What are your thoughts about the notice of advanced rule making by CMS that would allow states to consolidate their waivers based on functional need?

Terence Ng: Lewis, could you repeat the question, sorry.

Lewis Kraus: What are your thoughts about the notice of advanced rule making by CMS that would allow states to consolidate their waivers based on functional need?

Terence Ng: This was what was suggested in the DRA I believe. I have heard of very varying opinions on that. It sounds like a good idea. Because that would sort of consolidate the number of waivers and consolidate different kinds of waivers. And I think generally it's a good idea, but as usual the trick is the implementation and the communication of the program to consumers. So yeah, I think it's generally a good idea.

Lewis Kraus: The next question from Dr. Larry Weiss, is there any language in the new health reform or legislation that will make states more equitable and/or enhance HCBS?

Terence Ng: First question is, which health reform legislation?

[ Chuckle ] But I believe there is the class act meant to provide more personal care, to at least encourage personal care.

In states, right now, as you may remember, a personal care state plan is an optional program. Many states do provide personal care within their waivers. But there are limitations of waivers obviously. Not everyone in the state who may require them do get them. So I believe they are trying to get personal care legislation into the new health reform, but who knows what may happen?

Lewis Kraus: The next question is: And you may have answered this already, but, Kevin asked, say a few words about the community Choice Act and how it might impact the cost of LT S.F.

Terence Ng: Yes, the community Choice Act, what I talked about for class act. They changed the names many times. In terms of costs, hard to say, as with new programs, they almost always increase the cost in the very first couple of years, but hopefully as if it is an institutional avoidance program or at least a large means towards institutional avoidance then, I think, it should be able to save states and the federal government money over the long run.

Lewis Kraus: The next question is from Bill. He follows up with, "in Virginia the current budget proposals have caps on elderly disabled waiver as well as a rate reduction in payments to personal assistance of 5%. Given the already low rate of pay this seems to be an unfairly forcing the cuts on already strapped low-wage workers. Do you think that Virginia and other financially strapped states will actually do this?"

Terence Ng: Although I think states are not only looking at doing this, but doing a lot of more. There are a couple of states who are planning on introducing new service and cost caps when previously there wasn't any in that state. So I think the cost cap the caps wise, that is probably going to happen, but in terms of the rate reduction we can see a lot of times it's a really depending on who it's going to, but it's sometimes a pointed question, personal question, because we have to involve the unions and things like that, but in terms of rate reduction it's sort of drastic because most states would maintain that rate over a couple of years and that technically it is a rate reduction anyway. But to actually have a fixed number rate reduction is sort of drastic, hopefully they don't do that, but I will be surprised if they do.

Lewis Kraus: Okay. August points out I skipped one. Sorry. He asked: Has there been any comparison between Medicare-Medicaid services and VALTC services?

Terence Ng: There might be. I personally do not know of any. But I wouldn't be surprised if there was.

Lewis Kraus: Vicky asked. Is there any discussion regarding a single set of standards for people utilizing waiver services, e.g., MR/DD, versus elderly care, versus TBI, et cetera?

Terence Ng: Uniform set standards across target groups. It sounds like a good idea, but I think when we look at the deferring needs, the deferring services that these target groups will have, it's really hard to be able to say let's do that. The waivers what they do at least the waivers is that they are meant to substitute for a particular institutional level of care, either nursing homes, FFMRs or hospitals. And I can tell that you most of the hospital level of care are more either TBI or children's waivers. And these are really, really high acuity levels. So to try to have a uniform criteria across all three, it's going to be tough.

Lewis Kraus: And Andrew asks: The findings could be seen as treating nursing home and HCBS users as equivalent; is there any evidence regarding the comparative need levels of SNFN and HCBS users, e.g., through preadmission screening studies or even random assignment?

Terence Ng: I think I sort of addressed that, which is just in the previous question, which was that a waiver, at least for waiver programs, I know there's home health and personal care, home health is supposed to be institutional level persons. So they are meant to be equivalent or at least supposed to be on paper.

For HCBS waivers, they have they are supposed to serve people with the same level of need as someone either in nursing homes, ICFMRs or hospitals. So you will be we do treat them equivalent. And because they are supposed to, whether the execution of that doesn't work out that way, that's another matter. But they are supposed to be equivalent.

Lewis Kraus: The next question is -- and I have reposted the feedback form. Sorry I typed it in wrong.

Do you feel that states will utilize and promote adult day care as it is the most cost effective HCBS when all benefits versus costs are looked into?

Terence Ng: About day care, many of them are provided within Medicaid HCBS waivers and whether the most effective HCBS cost effective HCBS when all benefits, versus costs are looked into? I don't know. Whether that's the case, I don't know. But in terms of the use of adult day care, many of them are being used within ICFMR and especially the elderly waivers. So whether there has been an increase or whether there is a trend towards increasing that we have not looked into it right now.

Lewis Kraus: Okay. And the final thing to say and we are ten minutes over the time so I want to end and let people go back to their normally scheduled day. Kevin points out to Dr. Weiss from his previous question that he's pointing him to the community choice -- community first state plan option that's at http://www.adapt.org/cfc/php.

So that concludes today's presentation. Thank you very much for your time being here. For those of you on the East Coast, I hope we have given you a little bit of a respite from snow. And Terence, thank you very much for a great presentation. If you have further questions, you can email to Terence, and you can find the best way is email to him at the website. At www.pascenter.org under the about the center and there is a link to staff ask you can write to them there.

All right, thank you very much everyone and have a great day.