The Aging Population: A Medi-Cal Perspective...October 2016 DHCS - Research and Analytic Studies Division 10 Medi-Cal's Funding Mix: How Has It Changed? $21.8 $23.4 $24.3 $31.1 $28.8

The Aging Population:A Medi-Cal Perspective

October 2016

Created by the DHCS –Research and Analytic Studies Division

October 2016 DHCS - Research and Analytic Studies Division

Medi-Cal is a public health insurance program that provides free or low-cost health coverage for children and adults with limited income and resources.

+


Medi-Cal is a State & Federal partnership.

2

Medi-Cal covers: • low-income adults;• families with children;• seniors;• persons with disabilities;• children in foster care, as well as

former foster youth up to age 26;• pregnant women; and• individuals with special health

needs.

October 2016 DHCS - Research and Analytic Studies Division 3

How Many Californians Are Enrolled in Medi-Cal?

-10%

-5%

0%

5%

10%

15%

20%

25%

30%

35%

40%

-

2,000,000

4,000,000

6,000,000

8,000,000

10,000,000

12,000,000

14,000,000

16,000,000

% of California Population in Medi-Cal Year-over-Year % change Average Monthly Eligibles

Over 13.5 million beneficiaries

Medi-Cal covers 34% of all Californians

Medi-Cal Covers Half ofCalifornia Resident Births

23.4% 22.4%

36.1%

41.3% 42.4%46.0%

49.2%

50.7%

49.8%

0%

10%

20%

30%

40%

50%

60%

% o

f Cal

iforn

ia B

irths

4October 2016 DHCS - Research and Analytic Studies Division

Medi-Cal has covered more than 40% of California resident hospital births since 1992, and Medi-Cal proportions have increased even as total number of births has decreased.

In 2010, the proportion of births financed by Medi-Cal in California was 50.7%. In 2013, it was slightly lower at 49.8%.

5

Medi-Cal Covers More than Halfof California’s Children


Medi-Cal covers roughly six out of 10 children in the state. In some counties, Medi-Cal is the primary source of health care coverage for 80% of all children.

58%

36%27% 22% 23%

34%

42%

64%73% 78% 77%

66%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Age 0 to 17 Age 18 to24

Age 25 to44

Age 45 to64

Age 65 orolder

All Ages

With Medi-Cal Without Medi-Cal

Perc

ent o

f Sta

tew

ide

Popu

latio

n


Proportion of Californians Enrolled in Medi-Cal, By County (FFY 2013-14)

Medi-Cal is the primary health care coverage for many geographic regions of the state.

In some counties within the Central Valley, Medi-Cal provides coverage to more than 50% of the population.

7

Medi-Cal’s Role in FinancingLong-Term Care Services

October 2016 DHCS - Research and Analytic Studies

Percent of LTC Nursing Facility

Residents Relying on

Medi-Cal For Payment

65%

Percent of LTC Nursing Facility Residents Not

Relying on Medi-Cal

35%

Division

Among California's long-term care (LTC) residents, nearly two-thirds rely on Medi-Cal to finance their care.

Roughly 100% of individuals who reside in homes for the developmentally disabled rely on Medi-Cal to pay for their care.

Source: California Association of Health Facilities http://www.cahf.org/AboutCAHF/ConsumerHelp/GuidetoLongTermCare.aspx

http://www.cahf.org/AboutCAHF/ConsumerHelp/GuidetoLongTermCare.aspx


State Financing of Medi-Cal


In The Headlines – Medicaid’s Financial Burden


Medi-Cal's Funding Mix: How Has It Changed?

$21.8 $23.4 $24.3

$31.1 $28.8

$36.0

$42.7

$58.6 $58.9 $57.8

$14.3 $14.4 $15.4 $13.6 $14.7 $14.4 $16.1 $17.3 $18.0 $17.8

$0.9 $0.8 $0.9 $5.5

$2.1 $8.9 $10.8 $13.5 $14.1 $14.8

$37.0 $38.5

$40.5 $50.2 $45.5

$59.3

$69.5

$89.4 $91.0 $90.3

$0

$10

$20

$30

$40

$50

$60

$70

$80

$90

$100

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-17

Federal State General Fund Other Total

Federal funding sees sharp increase as ACA is implemented

$ in

Bill

ions

Federal funding has taken a larger role in financing Medicaid programs throughout the nation, and California is no exception.

The adoption of the Affordable Care Act (ACA), provider taxes, quality assurance fees, certified public expenditures, and other means have brought in additional federal funds that have allowed Medi-Cal to enhance the program and offer coverage to new populations.

Medi-Cal’s new adult population, which began enrollment in CY 2014, is financed entirely by the federal government for the first three years, phasing down to 90% in 2020.

State general fund spending has grown modestly over the past nine years.


Source: Medi-Cal Appropriation Estimate SFY 2016-17, http://www.dhcs.ca.gov/dataandstats/reports/mcestimates/Documents/2016_May_Estimate/M1601_Approp_Funding_Sum.pdf

Medi-Cal Budgeted SpendingBy Funding Source (SFYs 2007-08 Through 2016-17)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

59% 61% 60% 62% 63% 61% 61% 66% 65% 64%

39% 37% 38% 27%32%

24% 23% 19% 20% 20%

2% 2% 2%

11% 5%15% 15% 15% 15% 16%

2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 2015-16 2016-1

Federal State General Fund Other

7

Budgeted federal funds financed 64% of Medi-Cal spending in SFY 2016-17, while state-budgeted general funds financed 20%, and other funds accounted for 16%.

The major shift in funding proportions has been primarily driven by the absorption of the Healthy Families Program into Medi-Cal in 2013 (representing a 65-35 split between federal and state dollars, respectively); implementation of the ACA in January 2014; and the use of other funds (e.g. provider taxes, quality assurance fees, CPEs, etc.).

http://www.dhcs.ca.gov/dataandstats/reports/mcestimates/Documents/2016_May_Estimate/M1601_Approp_Funding_Sum.pdf


Medi-Cal Spending as a Percentage of California's Overall Budgeted General Fund Spending (SFY 2016-17)

K-12 Education42%

Higher Education

12%

Corrections and

Rehabilitation9%

Natural Resources

2%

Other8%

Medi-Cal14.5%

Other HHS12.5%

Health and Human Services

27%

Medi-Cal spending accounts for roughly 14% of the state’s general fund spending.

This is in line with U.S. averages that indicate that Medicaid represents roughly 14% to 18% of state general fund budgets.

State general funds consist of expenditures from revenues raised through income, sales, and other broad-based state taxes.

Sources: Medi-Cal Appropriation Estimate SFY 2016-17, Department of Finance – California’s Enacted Budget SFY 2016-17http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html

Total = $122.6 billion

http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html


Medi-Cal Budgeted Spending as aPercentage of State General Fund (SFYs 2007-08 Through 2016-17)

14.0%13.9%

18.2%

15.7%17.1%

15.1%

16.7% 16.0% 15.6%14.5%

0%

2%

4%

6%

8%

10%

12%

14%

16%

18%

20%

2007-08

2008-09

2009-10

2010-11

2011-12

2012-13

2013-14

2014-15

2015-16

2016-17

% o

f Sta

te B

udge

ted

GF

Spen

ding

Sources: California Summary Charts, Figure – Sum – 03 for select years. http://www.ebudget.ca.gov/Medi-Cal Appropriation Estimates for select years.

Medi-Cal spending as a percent of state-budgeted general fund spending has remained relatively stable over the past 10 years.

Medi-Cal has accounted for between 13.9% and 18.2% of budgeted general fund spending.

http://www.ebudget.ca.gov/


Medi-Cal Spending as a Percentage of California's Overall Budgeted Spending (SFY 2016-17)

Budgeted Spending Not

Medi-Cal$308.6 billion

(77%)

Medi-Cal Budgeted Spending

$90.3 billion(23%)

Total = $398.9 billion

Source: Medi-Cal Appropriation Estimate SFY 2016-17, Department of Finance – California’s Enacted Budget Sfy 2016-17http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html

Because Medi-Cal brings in substantial federal funds, another way to look at Medi-Cal in the context of state spending is to evaluate all state spending.

Medi-Cal spending accounts for roughly 23% of California’s overall state spending. Nationally, Medicaid accounts for 25% of overall state spending.

Overall state-budgeted spending includes federal, state, and all other funds combined.

http://www.ebudget.ca.gov/2016-17/Enacted/BudgetSummary/BSS/BSS.html

Medi-Cal Is Heavily Dependent on Federal Funding

• Medi-Cal covers 34% of all Californians,

including 58% of the state’s children, and

50% of all resident births.

• Federal contributions have increased

sharply, and now account for 65% of Medi-

Cal’s budget.

• Changes in federal policy in response to

budgetary pressures or economic downturns

may introduce complex and difficult funding

decisions in the future.


https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiO3bHI74LPAhVLSyYKHVbrAQcQjRwIBw&url=https://publichealthwatch.wordpress.com/2015/03/28/republican-states-are-far-more-dependent-on-government-new-analysis-shows/&bvm=bv.131783435,d.cWw&psig=AFQjCNHI-uzPfFjXJ33lp64PzSyCWOmgfw&ust=1473530537118843


Federal Financing of Medi-Cal


Source: Congressional Budget Office, An Update to the Budget and Economic Outlook: 2016 to 2026 https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf

17

CBO Baseline Budget Projections2016 Through 2026

-

1,000

2,000

3,000

4,000

5,000

6,000

7,000

2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026

Spen

ding

In

Billi

ons

Revenues Spending

Spending

Revenues DEFICIT

Federal spending is projected to exceed revenue from 2016 through 2026.

The Congressional Budget Office (CBO) predicts that spending for mandatory programs will rise nearly 70% in nominal terms from 2016 to 2026.

They attribute most of this increase to the aging of the population and rising health care costs per person.

https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf


What Is Driving Federal Deficits?

Major Health Programs

34%

Social Security29%

Net Interest19%

All Other Programs

18%

82% ofgrowth in spending isdriven by three categories


Federal spending is projected to grow substantially between 2016 and 2026.

The CBO estimates that 82% of the growth in federal spending will come from three major components: net interest; Social Security; and major health programs.

The major health programs include Medicare, Medicaid, Children’s Health Insurance Programs, and health care subsidies for the ACA.

https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/51908-2016_Outlook_Update-2.pdf


2015 Actual Federal Expenditures


Mandatory spending accounts for 62% of all federal spending. When interest on the debt is added in, mandatory plus interest accounts for 68% of all federal spending.

Social Security, Medicare, Medicaid, and other health account for 50% of all federal spending.

By 2026, the Congressional Budget Office estimates that mandatory spending plus interest on the debt will account for 77% of all federal spending.

Mandatory SpendingDiscretionary Spending

32% 62%

Interest 6%

Social SecurityNon-Defense24%16%

Defense Medicare16% 17%

Other Health and Income Sec.

MedicaidPrograms9%12%


Federal Debt Held By the Public Federal debt held by the public is projected to rise from 77% of GDP in 2016 to 86% in 2026.

According to the CBO, when the debt as a percentage of GDP reaches 86%, it would be more than twice the average over the past 50 years.

The CBO predicts, assuming no changes in laws, that three decades from now the debt held by the public will be about twice as high relative to GDP. This would be higher than the U.S. has ever experienced.

0

20

40

60

80

100

12019

40

1945

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

2020

2025

% o

f GDP

2016: Actual U.S. debt approximately $14 trillion (77% of GDP)

2026: Projected U.S. debt at $23 trillion (86% of GDP)

Deficits & Debt May Necessitate Reforms• The Medi-Cal program is highly dependent

on federal funding.

• Policy changes at the federal level may

greatly impact Medi-Cal in the future.

• Policymakers will have to consider a

combination of tax, spending, and

entitlement reforms.

• Federal and state governments, as well as

Medicaid stakeholders, are going to have

to work together and find more cost-

effective ways to deliver health care.



Actual Spending and Demographics:

Medi-Cal in FFY 2013-14

October 2016 DHCS - Research and Analytic Studies 23Division

Total Medi-Cal BeneficiariesN=12,952,327

$=87,910,546,884

The Medi-Cal Population in FFY 2013-14

Aged

n = 1,135,824 (9%)

$ = 30,891,905,156 (35%)

Medi-Cal$ = 13,697,792,859

(44%)

Medicare$ = 17,194,112,297

(56%)

Blind/Disabled

n = 1,247,546 (10%)

$ = 31,068,261,428 (35%)

Medi-Cal$ = 23,107,732,950

(74%)

Medicare$ = 7,960,528,479

(26%)

Low-Income

n = 10,568, 957 (82%)

$ = 25,950,380,299 (30%)

Medi-Cal $ = 25,300,972,398

(97%)

Medicare$ = 649,407,901

(3%)


More Females in the AgedEligibility Group

The Aged eligibility group included a much larger proportion of females (62%) vs. males (38%) compared to the other eligibility groups. This disparity is primarily driven by differences in life spans.

The Low-Income group also included a larger proportion of females compared to males, due to the fact that Historically, Low-Income eligibility pathways focus on women of child-bearing age, though this has changed.

38%53%

46%

62%47%

54%

Aged (n=1,135,824) Disabled (n=1,247,546) Low-Income(n=10,568,957)

Distribution of Medi-Cal Population inFFY 2013-14, by Gender

Male Female

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Sixteen Percent of Aged Eligibility Group is Ages 85 and Older

26%

52%

74%

48%

84%

16%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


FFY 2013-14, by Age Group

Ages 0-19 Ages 20-64 Ages 65-84 Ages 85 and Older

Distribution of Medi-Cal Population in

The Aged eligibility group was predominately comprised of individuals ages 65-84 (84%), with 16% being ages 85 and older. The Disabled group included a much larger proportion of eligibles ages 20-64 (74%) compared to the Low-Income group (48%).


Aged and Disabled More Likelyto Be Dually Eligible

88%

31%

0.4

12%

69%

99.6%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


Distribution of Medi-Cal Population inFFY 2013-14, by Dual Status

Dual Eligible Non-Dual Eligible

%

Dual Eligiblescomprised a majority of the Aged eligibility group (88%), while the Low-Income group was comprised almost entirely of non-Dual Eligible individuals.

Close to one-third of the Disabled eligibility group was dually eligible, and many were within the two-year disability waiting period.


Race/Ethnicity Vary by Eligibility Group

29.1% 27.1%

52.8%

24.0% 30.7%

18.4%17.0%20.1%

10.5%24.2% 6.9%

10.4%

5.4%14.5%

7.6%

0.3% 0.7% 0.4%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Aged Disabled Low-Income

Distribution of Medi-Cal Population inFFY 2013-14, by Race/Ethnicity

NativeAmerican

African-American

Asian

Missing /NotReported

Non-HispanicCaucasian

Hispanic

All Medi-Cal eligibility groups are ethnically/racially diverse. Hispanics and Non-Hispanic Caucasians represent the largest proportion of eligibles overall, and Native American eligibles represent the smallest proportion.

The demographic characteristics of elderly Medi-Cal beneficiaries are different from those of other Medi-Cal groups. For example, elderly Medi-Cal beneficiaries in the Aged eligibility grou p are 3.5 times more likely to be of an Asian race/ethnicity compared to the Disabled group, and 2.3 times more likely to be Asian compared to the Low-Income group.


Aged, Disabled Eligibility Groups Generate Disproportionate Spending

Medi-Cal spending is not equally distributed relative to population shares.

Medi-Cal's Low-Income population constituted 82% of the overall population, but accounted for only 30% of total spending.

In contrast, Medi-Cal's Aged population represented 9% of the overall population, but accounted for 35% of total spending.

Similarly, Medi-Cal's Disabled population constituted 10% of the overall Medi-Cal population and accounted for 35% of overall spending.

9%

35%10%

35%82%

30%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Unduplicated Eligibles(12,952,327)

Total Spending($87,910,546,884)

Medi-Cal Spending By Eligibility GroupFFY 2013-14 Dates-of-Service


Source: Medi-Cal and Medicare Eligibility data


Age and Health Care Spending –Aggregate Medi-Cal and Medicare Expenditures (FFY 2013-14)

-

50,000

100,000

150,000

200,000

250,000

300,000

350,000

$-

$200

$400

$600

$800

$1,000

$1,200

$1,400

$1,600

0 20 40 60 80

Elig

ible

s

Aggr

egat

e Sp

endi

ng (i

n m

illio

ns)

Age

Medi-Cal Spending Medicare Spending Eligibles

A substantial amount of overall Medi-Cal spending is generated by children and young adults, reflecting their greater numbers in the program. Medi-Cal spending rises sharply between ages 40 and 64, reflecting increasing numbers of disabled individuals in that age range. At age 65 Medi-Cal costs fall, reflecting the transition of responsibility for most coverage to Medicare. However, Medi-Cal’s costs do not fall completely, as Medi-Cal is still responsible for providing Long-Term Services and Supports (LTSS).


Age and Health Care Spending –PMPM Spending

-

50,000

100,000

150,000

200,000

250,000

300,000

350,000

$-

$1,000.00

$2,000.00

$3,000.00

$4,000.00

$5,000.00

$6,000.00

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 9510

0+

Elig

ible

s

Per M

embe

r Per

Mon

th S

pend

ing

Age

Medi-Cal PMPM Spending Medicare PMPM Spending

Eligibles

As displayed, “per member per month” (PMPM) spending is low in childhood and increase somewhat during young adulthood, reflecting the increased frequency of pregnancy and delivery.

Spending increases more after age 40, reflecting the increased frequency of disability and chronic disease. Medi-Cal PMPM spending declines somewhat after age 65, but begins steeply rising again at age 75 as the need for LTSS increases.


How Do PMPM Costs Vary by Eligibility Group?

$1,389

$566$7

$1,106

$1,642

$256$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000


Comparison of PMPM Spending in FFY 2013-14,by Eligibility Group

Medicare Medi-Cal

(Total = $2,495)

(Total = $2,208)

(Total = $263)

The Aged and Disabled eligibility groups generated the highest combined Medi-Cal/Medicare PMPM spending, illustrating the complex conditions associated with these eligibles.


Medi-Cal’s Aged Population


Projected Growth of the California Population Ages 65 and Older

0

2

4

6

8

10

12

14

2010

2012

2014

2016

2018

2020

2022

2024

2026

2028

2030

2032

2034

2036

2038

2040

2042

2044

2046

2048

2050

2052

2054

2056

2058

2060

Calif

orni

a Po

pula

tion

65 y

ears

of a

ge a

nd o

lder

(in

mill

ions

)

Aged 65-74 years Aged 75-84 years Aged 85 years or older

2029: +97% since 2010 (8,415,973)

2060: +185% since 2010 (12,211,957)

2010:4,281,051

The California Department of Finance estimated that there are 5.4 million Californians ages 65 and older in 2016. The number increases to 6.2 million by 2020, 8.6 million by 2030, 10.1 million by 2040, and 11.2 million by 2050.

While the number of individuals ages 65 to 74 increases at a lower rate after 2030, the 75-84, and 85+ cohorts will continue to grow at a steeper rate through 2060.



34

Eligibility Pathways for Medi-Cal’sAged Population

Aged-FPL18%

Aged-MN16%

Aged-PA3%

Blind/Disabled1%

LTC5%

Other<1%

Parent/Caretaker Relative

2%

SSI/SSP53%

Undocumented2%

N = 1,135,824

Medi-Cal provides low-income seniors with vital health care coverage.

Fifty-three percent (53%) of the Aged population are categorically eligible because they receive Supplemental Security Income/State Supplemental Payments (SSI/SSP).

Another 18% are eligible because they are enrolled through the Aged Federal Poverty Level program. Sixteen percent (16%) are eligible because they qualify under one of Medi-Cal’s medically needy programs. Five percent (5%) qualify because they require LTC services and are unable pay for it. Three percent (3%) qualify through public assistance; 2% qualify as parent/caretaker relatives; 1% qualify due to disability status but do not qualify for SSI/SSP; and a small group qualifies under one of the program’s other categories.


Gender Distribution Changes with Age California’s aging population consists of more females than males, and this disparity increases with age.

More than any other socioeconomic group, women are disproportionately affected by LTC.

The reason behind this lies in the fact that women live longer than men, on average, and are more likely to develop the functional ailments that require LTC services. Two-thirds of residents in LTC facilities are women.

45% 41% 40% 38% 37% 33% 29%22%

55% 59% 60% 62% 63% 67% 71%78%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ages 60to 64

Ages 65to 69

Ages 70to 74

Ages 75to 79

Ages 80to 84

Ages 85to 89

Ages 90to 94

Ages 95+

Gender Distribution By Age Group

Male Female

DivisionOctober 2016 DHCS - Research and Analytic Studies 36

The Aged Eligibility Group in FFY 2013-14Aged Eligibility Group

N = 1,135,824$ = 30,891,905,156

SpendingMedi-Cal = $13,697,792,859 (44%)Medicare = $17,194,112,297 (56%)

LTSS

Communityn = 314,733 (28%)

$ = 12,182,494,810 (39%)

Institutionaln = 108,646 (9%)

$ = 10,189,390,555 (33%)

No LTSSn = 712,445 (63%)

$ = 8,520,019,791 (28%)

MD

Eligibilityedi-Cal Only = 141,767 (12%)ual Eligible = 994,057 (88%)


Concentration of Health Care Spending Withinthe Aged Eligibility Group

Least Costly 50%

Most Costly 20%

0

10

20

30

40

50

60

70

80

90

100

Cum

ulat

ive

Perc

ent o

f Tot

al S

pend

ing

Percent of Medi-Cal Population Ordered by Health Care Spending

The most costly one percent of the Aged population generated 11.4% of combined spending and had a PMPM cost of $26,962.

The most costly five percent of the Aged population generated 29.7% of combined spending and had a PMPM cost of $15,055.

The least costly fifty percent of the Aged population generated only 10.6% of combined spending and had a PMPM cost of $547.

Most Costly 1

Most Costly 5%

Most Costly 10%

%


Combined Spending for Medi-Cal’sAged Eligibility Group, By Service Category (FFS); FFY 2013-14

As displayed, spending for inpatient hospital services account for 32% of all spending.

Payments for skilled nursing account for another 22% of spending, pharmacy accounted for 12%, and in-home supportive services account for 10%.

Inpatient Hospital

$4.44 32%

Skilled Nursing

$3.05 22%

Pharmacy$1.73 12%

Supportive Services

$1.33 10%

Physician and Clinical

$1.48 11%

Outpatient Hospital

$0.82 6%

Other$0.52 4%

Home Health$0.40 3%

Developmental Disability

Services$0.07 0%

Short-Doyle Mental Health$0.04 0%FFY 2013-14

In-Home


Aged, Disabled Eligibility GroupsGenerate Disproportionate Acute-Care Inpatient Hospital Days

Source: Medicare and Medi-Cal Claims and OSHPD Patient Discharge data

9%

33%10%

35%82%

31%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Eligibles(N=12,952,327)

Total Inpatient Days

Inpatient Acute Hospital Days By Eligibility GroupFFY 2013-14 Dates-of-Service

Low-Income

Disabled

Aged

The distribution of acute-care inpatient hospital days generated by each of the three eligibility groups closely mirrors the distribution of overall spending. This is not surprising, since inpatient hospital care is a major driver of spending.

Medi-Cal's Low-Inc omeEligibility gro upconstituted 82% of the overall population, but accounted for only 31% of hospital days. In contrast, Medi-Cal's Aged eligibility group, representing only 9% of the overall population, accounted for 33% of hospital days.


Acute-Care Inpatient Hospital Daysper 1,000 Member Months

176

165

21

52

- 50 100 150 200

Aged

Disabled

Low Income Beneficiary

Overall

Acute IP Days / 1,000 Member Months

Days / 1000 MM By Eligiblity Group

173

890

73

176

- 200 400 600 800 1,000

LTSS-Community

LTSS-Institutional

No LTSS

Overall

Acute IP Days / 1,000 Member Months

Aged - LTSS Status

Acute-care inpatient hospital use is highes tamong Medi-Cal’s Aged eligibility group.

The Aged eligibility group generated an acute-care inpatient hospital days per 1,000 member months rate that was 3.3 times greater than Medi-Cal’s rate overall, and more than 8 times greater than the rate seen in Medi-Cal’s Low-Income eligibility group.

Aged individuals residing in LTC facilities had the highest rate (890 days/1,000 member months).


74.3%58.7%

45.2%42.6%42.3%

38.3%29.2%

26.5%24.3%

22.6%21.1%

19.3%18.8%18.3%

16.4%16.3%

15.5%13.8%

12.3%12.1%

9.9%9.1%9.0%

8.0%7.8%

0.0% 20.0% 40.0% 60.0% 80.0%

HypertensionHyperlipidemia

DiabetesRheumatoid Arthritis

AnemiaIschemic Heart Disease

CataractChronic Kidney Disease

Heart FailureDepression

Alzheimer's Related…Depressive Disorder

COPDPeripheral Vascular…

HypothyroidOsteoporosis

GlaucomaAnxietyObesity

Benign ProstateAsthma

Alzheimer's DiseaseAtrial FibrillationHearing Impaired

Stroke / TIA

Most Frequently Diagnosed Clinical Conditions Among the Aged Eligibility Group

Source: FFS Medicare and Medi-Cal claims and encounter data for calendar years 2013 and 2014.

Among the Aged eligibility group, the most frequently diagnosed clinical conditions include hypertension (74.3%), hyperlipidemia (58.7%), and diabetes (45.2%).

Alzheimer’s and other related disorders were also prevalent among the population (21%).


Most Costly Clinical Subpopulations In terms of combined Medicare and Medi-Cal PMPM spending, the most costly clinical subpopulations among the Aged eligibility group included acute myocardial infarction ($9,750), hip fracture ($9,145), and pressure ulcers ($9,106).

$9,750 $9,145 $9,106

$8,810 $8,483

$8,269 $8,187

$8,010 $7,805 $7,705 $7,644 $7,534 $7,517

$7,344 $7,178 $7,045 $7,026

$6,710 $6,420 $6,280 $6,229 $6,206

$6,033 $5,995 $5,876

$- $2,000 $4,000 $6,000 $8,000 $10,000 $12,000

Acute Myocardial InfarctionHip Fracture

Pressure UlcersSpinal Cord Injury

Traumatic Brain InjuryEpilepsy

Mobility ImpairmentsIntellectual Disbilities

Other Developmental DisordersMuscular Dystrophy

Schizophrenia and Other PsychosisMultiple Sclerosis

Lung CancerBipolar Disorder

SchizophreniaStroke or TIA

BlindHIV AIDS

Hepatitis C -UnspecifiedAtrial Fibrillation

LeukemiaAlzheimer's Disease

Peripheral Vascular DiseaseAlzheimer's Related Disorders

Hepatitis C -Acute

Source: FFS Medicare and Medi-Cal claims and encounter data for calendar years 2013 and 2014.


Impact of Multiple Concurrent Clinical Conditions

Source: Medicare claims and encounter data for calendar years 2013 and 2014; CMS Chronic Condition Warehouse (CCW) algorithms utilized to create chronic conditions. PMPM spending represented combined Medi-Cal and Medicare.

$144 $552 $974 $2,197

$5,610

$12,136

$-

$2,000

$4,000

$6,000

$8,000

NoConditions

1 to 2Conditions

3 to 4Conditions

5 to 9Conditions

10 to 15Conditions

More than15

Conditions

No Conditions

8% 1 to 2 Conditions

8%

3 to 4 Conditions

14%

5 to 9 Conditions

40%

10 to 15 Conditions

24%

More than 15

Conditions6%

Combined Medicare-Medi-Cal PMPM Spending

$14,000

$12,000

$10,000

The CMS Chronic Condition Warehouse (CCW) algorithm identifies 60 different chronic and potentially disabling clinical conditions.


Distribution of Spending for Aged Eligibility Group by LTSS Status

Combined health care spending among Medi-Cal's Aged population is concentrated among those who are institutionalized.

Individuals who were LTC institutional utilizers represented 10% of the Aged population, but accounted for 33% of total combined Medi-Cal and Medicare spending.

Aged individuals who did not use LTSS throughout FFY 2013-14 comprised 63% of the Aged population and accounted for only 28% of overall combined spending.

Members of the Aged population who utilized LTSS not classified as institutional accounted for 28% of the Aged population and generated 39% of overall combined spending.

28%39%

10%

33%

63%

28%

Unduplicated Users(1,135,824)

Total Spending($30,891,905,156)

Aged Spending by LTSS Status

LTSS-Community LTSS-Institutional No LTSS

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

October 2016 DHCS - Research and Analytic Studies


Division 45

Combined Per-Capita Spending forthe Aged Eligibility Group by LTSS Status

$19,194

$48,286

$3,384$12,060

$19,514

$45,499

$8,575

$15,138

$0

$10,000

$20,000

$30,000

$40,000

$50,000

$60,000

$70,000

$80,000

$90,000

$100,000

LTSS-Com.($38,707)

LTSS-Instit.($93,785)

No LTSS($11,959)

Overall($27,198)

Spen

ding

Per

Cap

ita

Total Medicare Spending Per Capita Total Medi-Cal Spending Per Capita

Health care spending per-capita varied significantly based on whether the individuals needed LTSS.

Individuals who utilized institutional LTSS had the highest per-capita cost ($93,785). Individuals who utilized LTSS not classified as institutional generated per-capita costs of $38,707. Aged individuals who utilized no LTSS generated a per-capita cost of $11,959.

Differences in per-capita costs were the result of a number of factors, including age and health conditions.


Future of Health Care Faces PressuresMedicaid, like the nation’s entire health care system, will be challenged in the future. The aging population, budget deficits, and competition among limited resources will all require innovative and creative approaches to achieve sustainability.

The Future

Medicare is Not Free

(Cost-Sharing/

Copayment)

No National Financing

Plan for LTC

Retirement Preparation?

Federal Budget Deficits

State Budgets Must Be Balanced

Capacity of Health Care

Delivery System

Technology Impact

Demographic Trends – Aging

Population