Long Term Care: Where Are We and What’s Next?

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)

Speaker 1: The broadcast is now starting. All attendees are in listen only mode.

Kathryn M.: Hello, and welcome to our webinar on Long Term Care: Where Are We and What’s Next?

Speaker 1: Muted.

Kathryn M.: My name’s Kathryn Martucci. I’m the Director of Policy and Programs at the Alliance for Health Policy, and I will be introducing today’s discussion. For those that are not familiar with the Alliance, we are a non-partisan organization dedicated to advancing knowledge and understanding of health policy issues. We do not lobby or advocate, or take any policy or political positions ourselves. Instead, our mission is to educate the health policy community.

Kathryn M.: During today’s webinar, our panelists will explore the landscape of our current long term care delivery system, its funding mechanisms, and the impact that it has on stakeholders, such as older adults and caregivers. The Alliance for Health Policy gratefully acknowledges the National Institute for Healthcare Management Foundation for supporting our Beyond the Beltway health webinars for journalists series. We would also like to thank the Association of Healthcare Journalists for their help in shaping this series.

Kathryn M.: If you’re interested in joining the Twitter conversation, you can use the hashtag, AllHealthLive, and follow us at AllHealthPolicy.

Kathryn M.: I want to briefly orient you to the GoToWebinar platform, and go over some technical notes. We’ve taken a screenshot of the attendee interface, so you should see something that looks like this on your computer desktop in the upper right hand corner. You can click the orange arrow to minimize and maximize this menu. When you join today’s webinar, you were muted, and you will be throughout the presentation; but you can use the question panel to chat with us about any technical issues that you might be experiencing, and also you can send questions that you may have for the panelists there at any time. We’ll be collecting those throughout the broadcast and addressing them.

Kathryn M.: So here’s our agenda for today. First we’ll have each of our panelists make some opening remarks to orient you to the long term care system. Then, we’ve allotted plenty of time for audience Q&A and moderated discussion. So again, feel free to be sending questions at any time. You will also find all of the materials that accompany this webinar, including a copy of the slides, a resource list, and an experts list, on our website, AllHealthPolicy.org; and then a recording of the webinar will be made available there in a couple of days.

Kathryn M.: So now I have the pleasure of introducing our guest moderator for the day. Rachana Pradhan is a healthcare reporter for POLITICO, where she focuses on Medicaid and ACA private insurance markets. Prior to this position, she worked at Inside Health Policy for three years, and was also a city government reporter at The Daily Progress in Charlottesville, Virginia. She is a recognized health policy expert and has appeared on multiple media platforms such as CNN, MSNBC, Fox News, and CSPAN. So we are very honored that she has decided to lend her expertise and her moderating expertise with us today. So with that, I will hand it over to you, Rachana. …

Kathryn M.: It’s maybe on mute, Rachana, are you-

Rachana Pradham: [crosstalk 00:03:40] I’m just going to … I am. Can you all hear me?

Kathryn M.: Yup, you sound great.

Rachana Pradham: Great, so let me just … I’m going to briefly just introduce all of our panelists who are joining us today. Then we’ll get started right away.

Rachana Pradham: So first, is Anne Montgomery. She is the Deputy Director at the Altarium Institute’s Center for Elder Care and Advanced Illness where she manages a portfolio centered around the coordination and integration of medical care and long term services for the aging population. Anne was formerly a congressional staff member for both the Senate’s special committee on aging, and the House Ways and Means committee.

Rachana Pradham: Next, we have Jean Accius. He’s the Senior Vice President of Thought Leadership and International Affairs at AARP. He provides expertise on the aging population, both domestically and internationally. Jean has been recognized as a Gerontological Society of America Fellow, and received the Share Care Award for his groundbreaking work documenting male family caregivers.

Rachana Pradham: Next we have Camille Infusi Dobson, who’s the Deputy Executive Director at Advancing States where she provides guidance to state aging and disability agencies on managed long term services and supports, and quality management. Prior to her current role, Camille worked at CMS for 10 years managing Medicaid policy and operations.

Rachana Pradham: Finally, we have Maureen Hewitt, who’s the President and Chief Executive Officer of InnovAge. In this role, she leads the strategizing and growth of the largest provider of PACE.

Rachana Pradham: So now we’re going to have Anne start, who will go over for us the current state of long term care.

Anne Montgomery: All right. Well, good afternoon friends and colleagues, and many thanks to the Alliance for Health Policy. It’s one of my very favorite organizations, and that’s because I had the honor of working there years ago with Ed Howard and also alongside Sarah Dash when we were both serving on Capitol Hill. Okay, next slide.

Anne Montgomery: So here’s a little bit about Altarium, just to give you give a sense of what we do. We’re a health services research organization, and at the Program to Improve Elder Care, which I now have the privilege of co-directing, we work hard to come up with solutions that improve any number of aspects of elder care. We have projects looking at financing quality workforce and more. Next slide.

Anne Montgomery: This is a comparison of where we’ve been and where we’re going. This is over only 10 decades from 1960 to 2060. I think it’s an astonishing demographic shift, and I never really tire of marveling at the progress that this slide highlights. Not withstanding political turbulence, we’ve made huge progress in providing better and better healthcare services, and our public health system has done wonders in preventing and controlling infectious diseases. Now we’re in an area where chronic disease and the functional limitations that characterize old age are becoming paramount; and that’s what we’re talking about today. Next slide.

Anne Montgomery: Spending however, current spending, is not reflecting the needs and priorities of a surging older population of frail elders, which who need access to an array of non-medical supportive services such as those covered by the Older Americans Act. You can see the yawning gap here. This chart focuses on Medicare, and the contrast between spending in that program and the Older Americans Act; and the gray bars represent population growth. We’ll talk about Medicaid a little bit later.

Anne Montgomery: A decade from now, that upward curve for Medicare is projected to go up far more sharply unless we make significant changes starting now. We’re in the process of adding tens of millions more older Americans who will be increasing seeking long term care. So, it seems very important to quickly engineer a series of multiple changes in service delivery through policy shifts. That means working with Congress, with states that mainly administer Medicaid, and with local governments and willing stakeholders. We have a great panel to discuss all this. In other words, our abbreviated timeline of 10 years suggest it would be a good idea to develop a strategy that we all work from, and that can be rapidly executed, and which modifies and improves on what we have in place. That’s the angle I’m going to be taking today. Next slide, please.

Anne Montgomery: Let’s talk about what states can do first. We know that states have done a lot over the years to diversify their LTSS systems, but there’s still a ways to go. Here are data that show this from IBM Watson Health from all states except California and South Carolina. In terms of HCBS spending, we have states that range from 27 to 81% of their total long term care spending, and the average is 57%. There are major disparities between populations, with 78% of LTSS spending on the [IDI/DD 00:08:24] population dedicated to HCBS compared to 45% for older adults and individuals with physical disabilities. We have an awful lot of people on HCBS waiting lists. 656,195 across the country in fiscal year 2016, for [1915(c) and 11-15 00:08:42] waivers alone.

Anne Montgomery: So how can we best address these challenges? Next slide. Here’s one way: we can shape an initiative to expand the infrastructure for HCBS. There’s no conference on long term care that I’ve ever been to that doesn’t note the incredible lack of capacity that we have in affordable, accessible disability adapted housing in the direct care workforce, in transportation supports for people who use wheelchairs, and in supports for family caregivers. Such an initiative is in the making right now. There’s interest both in the Senate and in the House of Representatives in shaping a bill that will be called something like the HCBS Infrastructure Improvement Act. It will propose substantial grant funding for states that submit plans to make clear progress in continuing to shift their LTSS spending toward HCBS, along with coverage gains, and that build infrastructure in these areas. Next slide.

Anne Montgomery: Without getting too much into the weeds, such a program, and it would not be small, would be a major one time investment in state HCBS capacity. A similar program that ran for five years, the Balancing Inventive Program that I was privileged to work on when I was on Capitol Hill, provided states with grants to make gains; and they all did. They got FMAP enhancements, Federal Matching Assistance Percentage enhancements to do the work. So there’s already a solid successful precedent for this approach.

Anne Montgomery: Here’s how a formula could be constructed. We’ve done an initial run using these percentages for what states would get in terms of additional funding. These are the percentage increases states could apply for relative to their HCBS baseline spending. As you can see, similar to the Balancing Incentive Program, states that needed the most help to make progress in shifting to HCBS would qualify for grants at a higher percentage. In the last couple of years, we suggest also tying the funding not only spending, but to enrollment gains as well. With states that are already well along the HCBS trajectory, those getting .25%, being required to hit a target of moving 85% of their LTSS population to the HCBS sector, and states getting a .5 increase would be required to achieve 75% of all Medicaid beneficiaries enrolled in HCBS settings and so on.

Anne Montgomery: A program like this could be five years, or seven years, or some other duration. It could be capped in total funding, or it could be open ended. It could make all of the targets mandatory that we saw in the last slide, or only some of them. So there are lots of levers and ways of making it work to fit the political circumstances of the House and Senate, and we’ll see what’s possible. But if we can do this, it will result in enormous improvements and gains in long term care; and because housing and transportation and workforce are essential to Medicaid but not in Medicaid, there would be a great deal of work done in information technology in order to coordinate and integrate with programs that are administered by other agencies. Next slide.

Anne Montgomery: Now I’ll turn to Medicare and offer up two practical ideas that I hope you’ll like for making progress in the near term. One focus is on Medigap, which has more than 13 million policies out there, and which could be used to offer a low key and potentially actionable way to tackle the front end risk of needing long term care. Medigap is purchased by beneficiaries in the Medicare for fee service sector. We’ve already taken good steps to improve the Medicare advantage program a couple of years ago, with regard to enhancing MA plan flexibility to offer optional supplemental LTSS benefits. So, the basic idea of this is why not do something similar on the fee for service side? If Congress wanted to do this, we could build on the expertise of the National Association of Insurance Commissioners, which represents state insurance regulators across all states, NAIC develops state model laws, it created the original framework for the Medigap market when Congress directed it do that in the 1990 law.

Anne Montgomery: So if the ways and means, and the finance committees decided to slightly expand Medigap, they could call for NAIC to develop a modest limited array of in home supportive services for personal care assistance, for home delivered meals, for care coordination, and perhaps a few other services. These are services that have been studied in depth by actuaries in Minnesota who have projected only a modest impact on Medigap premiums. There are ways of improving comprehensive long term care insurance, too, and there will be testimonies to that effect later this week in the health subcommittee of the Senate finance committee. In general, however, the longterm care insurance market has been struggling, and premiums have been going up, and for many existing policy holders, that’s presented difficulty. So it’s a troubled market. Next slide, please.

Anne Montgomery: In thinking more about existing Medicare programs and how we can enhance and scale them, PACE comes to mind. I know we’ll hear more about that later. At Altarium, we’ve been looking at PACE for the last couple of years, and how it can be used to slow spend down in Medicaid; because Medicaid won’t be able to fully absorb millions and millions more older adults who are accessing it mainly in order to get long term care. We simply must build better capacity that Medicare beneficiaries can easily and reliably access and use.

Anne Montgomery: What we’re recommending for PACE is to create a clear pathway to enroll Medicare only beneficiaries, which is really very difficult today. To make that happen, we’re going to have to reduce the costs of Part D coverage, which is astronomically high due to a statutory conflict between the 1997 PACE originating statute and the 2003 Medicare Modernization Act that added prescription drug coverage to Medicare. Today, if you’re a Medicare beneficiary wanting to buy into PACE and you can afford to pay for your own long term care because you’re not eligible for Medicaid, you’re forced to buy the PACE Part D plan, which is 10 to 20 fold more expensive than a regular standalone Part D plan.

Anne Montgomery: There are many reasons for this sticker shock, which we can talk about during Q&A if you’re interested. But right now, let’s skip to the solution, which is to give Medicare beneficiaries a choice of buying either a local Part D prescription drug plan, which is often about $50 a month, or the more costly PACE Part D plan, which can run $800 to $1200 a month depending on where you are. If we take this step, then I think we can include PACE in the array of first class Medicare providers. Next slide.

Anne Montgomery: Then, we can do a lot more. We can take PACE and make it the healthcare hub for a locally anchored system of care that connects with many, many different community based organizations that offer supportive services; I’m thinking of those in the aging network and elsewhere. The hub could be an MA plan, too, or perhaps a federally qualified health center, or some other healthcare provider. But PACE, with its community infrastructure, its medical centers, its salaried interdisciplinary teams, its reliable transportation system, has a long track record of serving communities really well, and not pulling in and out depending on quarterly earnings; so it’s poised to do a particularly good job.

Anne Montgomery: The various components of this puzzle piece are basically how we at the Program to Improve Elder Care with thanks to [Joe and Lynn 00:15:49] for leading the way, conceptualized what a community anchored mixed healthcare and long term care system would include. We can talk about that more if you’re interested. Next slide.

Anne Montgomery: Now I’ll just say thank you. Thanks so much.

Rachana Pradham: Great. Thank you so much, Anne. So now I’m going to turn it over to Jean, and Jean is going to discuss older adults caregivers and existing federal programs. Take it away.

Jean Accius: Great. Well, thank you very, very much, and thank you Anne for that great presentation. I thought that what I would actually do is just give you some background information in terms of AARP, and then give four key takeaways from my presentation today. So if we were go to get … Next slide.

Jean Accius: So I would like to just start off by just giving you a sense in terms of exactly who we are as an organization. We were founded over 60 years ago by Dr. Ethel Percy Andrus, who was a retired principal who went looking for a retired friend, who was a retired teacher; and found her living in a chicken coop. Outraged by that experience, she created AARP, an organization founded with the full focus of insuring that older adults could age with dignity, independence, and purpose. For more than 60 years, we’ve been on this mission. So we’re a non-profit, non-partisan organization. We’re dedicated to empowering people to choose how they live as they age. We have over 38 million members, and offices in every state, Puerto Rico, and the US Virgin Islands. Every day, we work to strengthen communities and advocate for what matters most to them, as well as their families; that primarily focused on health security, on financial stability, and personal fulfillment. Next slide.

Jean Accius: So there are a couple of key takeaways from our presentation today. The first one is that the population is aging, growing, and living much longer. The second is that the demand for long term service and supports will more than likely increase. The third is that as baby boomers age, there will be fewer family caregivers to support them. There should be one more bullet there that talks about now is the opportunity, and that opportunity is to really think about innovative solutions that cross across public and private sectors to help address the challenges, and ensure that people can actually age with options. Next slide.

Jean Accius: So this slide gives you a good sense in terms exactly of the population growth and why we’re having a conversation today. There’s about 10,000 people who are turning 65 each and every day. According to the US Census Bureau, within the next couple of years, the number of older adults will exceed the number of children for the first time in US history. This has significant implications particularly for the work that we’re doing, and thinking about how this might impact communities, sectors, and systems. What you see on this slide is that the population age of 85 plus, which is a cohort that’s the highest need for long term service and supports, is projected to triple between 2015 and 2050. You can also see the growth by the other population as well. So the fastest growing age group is the 85 plus population, and then the second fastest growing is the 75 to 84. So we have a tremendous opportunity to think about exactly what does it mean in terms of population that’s aging, and growing, and living much longer? Then, the other aspect, I would just say is the fact that this also has implications for family caregivers. Next slide.

Jean Accius: As you can see by this slide, the cost of long term service and supports exceeds what families can afford across the country. The average cost of a nursing home in the United States is roughly about $97,455. For a private nursing home stay in the US, what you see here is the fact that it would consume about 231% of an older middle income family’s income. For a semi-private room, you’re looking at about $87,600. That would consume about 208% of someone’s income. When you look at the medium rate of a private bedroom in an assisted living facility, that’s roughly around $45,000 a year. That would consumed roughly about 107% of a typical older family’s income. Then, just looking at home care, which is roughly around $33,540 a year. We’re just making the assumption here that this is care for about 30 hours a week from a licensed non-Medicare certified home health aid. What you see here is that, that would consume more than three quarters, or 80%, of the median income of older households. So one of the key points when you look at this slide is the fact that the high cost of long term service and supports, unaffordable across the country and for most Americans. Next slide.

Jean Accius: Family caregivers are the backbone of our long term service and supports system. We just released a major report last week looking at the value of family caregivers, and there’s roughly about 41 million family caregivers in the United States. These are family members, neighbors, friends who are helping each other and providing what many would consider to be very complicated medical nursing tasks, such as giving injections, wound care, tube feeding, in addition to helping with bathing, eating, dressing, as well as providing assistance with transportation, finances. They, family caregivers, provide the majority of long term service and supports in our country. They are critical partners in helping individuals remain in their homes and communities. Caregiving is now a widespread issue, is a public issue, in part because of the fact that so many people are caregiving, or likely will become a caregiver. This crosses all political ideologies. This crosses all different age groups; one in four of caregivers are millennials. 40% of caregivers are men. So there’s a great opportunity to think about ways in which to actually support family caregivers.

Jean Accius: The report that we released last week found that family caregivers provided in 2017 roughly 34 billion hours of care, and the economic value of that unpaid care was roughly around 470 billion dollars. So if you take into account that we have a population that’s aging, that the vast majority of individuals receive care from a family member or friend, and that these family members and friends are providing care at the tune of about 470 billion dollars on an annual basis, and then take into account that the number of family caregivers will unlikely keep up with the pace of the aging of the population, there’s some opportunities to think about ways in which we start to support and recognize these family caregivers. What you see on this slide is just a ratio, and what you can see here is that there’s almost seven caregivers for every one older adult. By 2050, that declines from seven family caregivers to one older adult. Next slide.

Jean Accius: In addition to these caregivers providing the care, they experienced significant out of pocket costs. We did a study in 2016 that found that the average family caregiver was spending about 20% of their income on caregiving activities. So that’s roughly about $7,000. For caregivers who were providing care for long distance, that was roughly about close to $12,000. Next slide.

Jean Accius: Several years ago in 2011, the AARP Public Policy Institute created the state score card. This right here is … We started the conversation back in 2011 wanting to get a sense as to what is a high performing system? What would that actually look like? We worked with [inaudible 00:24:17] advisory group. We came up with a framework that basically highlighted these five dimensions; and that a high performing system would include be affordable and accessible, that there would be adequate choice of setting and the provider, that quality of life and quality of care would be a critical component to the system, that there would be support for family caregivers for many of the reasons I just mentioned in the previous slides, and that there would be effective transitions between one setting to another. Next slide.

Jean Accius: Just to give you a sense, so this framework was for the operationalized that in a high performing system, that consumers should be able to easily find and afford the services that they need, and that there be a safety net for those who cannot afford the services. Under choice of setting and provider, that the system would be person and family centered, and that there’ll be a place of high value on allowing consumers to exercise choice and control over where they receive services and who provide them. Under quality of life and quality of care, this was looking at the opportunity to really ensure that the services maximize positive outcomes for consumers, and that they’re treated with respect and that their personal preferences are honored; going back to what I was referring to in terms of our founder and her vision for older adults in this country.

Jean Accius: Then, that in terms of support for family caregivers, that family caregivers, their needs will be assessed and addressed so they can continue to provide their caregiving role without being overburdened or stressed; and that in terms of effective transitions, that there would be a seamless transition between one setting to the next. When you look at these five different dimensions, you are able to collectivize data under each dimension, to be able to assess how a state is actually doing. So the scorecard is multidimensional where you can actually look at a state performance at an indicator level, or at a dimension level, which is these five; and then overall. Next slide.

Jean Accius: What you find here, these are the overall rankings. So when you take into account the 25 different indicators across these five different dimensions, and you get an overall score. What you find is the fact that there’s great variation across the United States in terms of the systems of care, with respects to the delivery of long term service and supports. We can get into a conversation in terms of exactly what are the opportunities here. When we released our scorecard back in 2017, the number one state was Washington. Oregon and Minnesota were not too far behind. California is ranked nine. We can talk about some of the other states as well. The wonderful thing about this scorecard is the fact that even the high performing states like Washington state, Oregon, or Minnesota, or California, there are still opportunities, particularly at the indicator level, to improve. So there’s always opportunities to continuously improve to deliver services for older adults and people with physical disabilities. Next slide.

Jean Accius: So some of the key findings from this report is that states must pick up the pace of change to meet the needs of a growing number of people who are aging, and also living with a disability. As I indicated before, you have a significant population who’s aging and needing services. The other point from this report is that where you live matters significantly. We can get into this conversation as well, and what are some of the policies that are in place to think about ways in which we can insure that people can receive services in the setting of their choice, and that is also cost effective. The third key finding is around measurement. What we found was the fact that for those indicators where there was a tension, where there was federal and state initiatives, Anne talked about [BIP 00:28:03] as a perfect example, and stakeholder engagement, we saw a significant movement, particularly for those indicators. Then finally, Medicaid is a major driver of change. I know that Camille’s going to get into a Medicaid. So next slide.

Jean Accius: So where do we go from here? Some of the things I think that’s important to think about, and we can have this conversation, is that as we think about strategies for not financing long term services and supports because of the cost … it’s unaffordable for the vast majority of Americans in this country; it’s important to think about what are those public and private sector solutions? No one sector can actually address the financing question by itself. So really thinking about exactly what are the opportunities, which gets to my second bullet, around the shared responsibility, the appropriate role for government, for individuals, and private sector. Giving the significant support that families and friends are providing, in terms of the care that they’re providing, it’s critically important to think about ways in which we can recognize and support them. There’s been some great efforts and great initiatives, particularly around the National Advisor, the RAISE Act, that’s focused on looking for … across the federal system looking for innovative ways to support and recognize family caregivers.

Jean Accius: The other bullet is around innovation and encouraging experimentation with new ways of organizing care. We heard some ideas from Anne, and many states are in different conversations about different innovations that they want to implement. The other bullet I would mention is that one of the key things we know from constant surveys that we’ve done here at AARP is that the vast majority of people would prefer to remain in their homes and communities for as long as possible. Oftentimes, receiving services in your home is more cost effective than going to another setting. So thinking about ways to ensure that there is … that the policies that are in place are on equal footing, around going into an institution rather than going into a home and community base, services to receive care is critically important. Then finally as we think about the delivery system of the future, we want to ensure that it is really focused on the person and the family, and that the system is being responsive to their individual needs and their preferences.

Jean Accius: Then finally, I just want to say thank you. I think this is a great conversation. I am looking forward to the questions.

Rachana Pradham: Great. Thanks so much, Jean. Now we’re going to turn it over to Camille who will be reviewing programs at the state level.

Camille I-D: Thanks so much for having me today. Good afternoon. For those of you that are … do not know who we are, Advancing States is the new name for the National Association States United for Aging and Disability, or NASUAD. We represent state aging and disability directors who manage LTSS programs at the state level, both Medicaid funded and non-Medicaid funded. We focus our efforts here as a membership association on helping states deliver high quality, long term services and supports both to older adults and people with physical disabilities. Next slide.

Camille I-D: So as Anne and Jean both mentioned, family caregivers provide the bulk of unpaid care for individuals who need LTSS in the country. But on for paid care, after out of pocket costs paid by consumers and family members, Medicaid is the largest payer of long term services and supports. As you may know, there is little to no Medicare coverage for long term services and supports past acute skills and need for nursing home care. There is virtually non-existent employer private coverage for LTSS; and sadly, there are few individuals who actually have long term care insurance policies that might cover LTSS. So really Medicaid is the focal point for conversations about delivering and sustaining long term services and support systems. Next slide.

Camille I-D: So as I said, states and our partners in the federal government really are on the hook to address the growing demand and need for long term services and supports that both Anne and Jean mentioned. This slide is top of mind for our state agencies. While most people think that Medicaid is covering pregnant moms and kids, and they do, in fact, in terms of pure numbers, most of the expenditures, more than half of the expenditures though, the states make are for older adults and people with disabilities. So addressing that component of the Medicaid program is really top of mind for state. Next slide.

Camille I-D: This is the same data that Anne showed in the [MAT 00:33:13] format. I like this one better because it’s pretty clear from top to bottom where states are in terms of successfully spending as much of their Medicaid funds as possible on community settings, which as Jean said, is where most people would like to receive their services. The national average is right now around 57%. There are number of states, you can see the same kinds of states that were at the top of the LTSS scorecard from AARP are also being very successful in delivering services in a community setting, but there’s a lot of opportunity for those states in the upper half of this chart to make in roads into serving people in the community, and not in institutional settings. Next slide.

Camille I-D: As Anne said, that graph is actually very misleading because it includes all LTSS expenditures. As Anne mentioned, individuals with intellectual developmental disabilities are largely, not in every state, but largely served in community settings and so it skews the average upwards in terms of HCBS expenditures. What it masks is the fact that only 45% of older adults and people with disabilities are served in community settings. While that’s an increase, a great increase since 2002 when only … when less than half of that, those individuals, were in community settings. There are lots of opportunities to serve individuals both to divert individuals from entering nursing facilities, as well as identifying individuals who can safely live in community settings. Next slide.

Camille I-D: So one of the activities that states have undertaken in the last five to seven years to address the challenges of growing demand for LTSS is moving their systems to a managed care delivery system. We call that MLTSS, Managed Long Term Services and Supports. It’s a system in which like most Medicaid individuals who are also in managed care, the state transfers both responsibility and payment for long term services and supports to capitated managed care companies both for profit and not for profit in their state. It can include both institutional services like nursing homes, as well as home community based services; but the state itself decides which LTSS services the health plans will be responsible for. Next slide.

Camille I-D: So these are a number of the reasons why states are pursuing MLTSS programs, and you can see many of those address the challenges that both Anne and Jean have already laid out, the states are able to use health plan contracts to drive accountability, rather than having individual contracts with four or 5,000 providers. They can focus their time and attention really on a handful of health plans with strong and vigorous contract requirements that demand high performance from the health plans. States have also had some limited success at this point addressing the waiting list that Anne mentioned. There are a number of states around the country that have more demand for home community based services than they have capacity to provide; mostly because the Medicaid program requires the states to offer nursing facility services as a benefit, but does not require them to offer home and community based services. So they are challenged to manage that balance, and they have found health plans are effective partners in helping to move individuals off of HCBS waiting lists and into services.

Camille I-D: Back to the graph that I showed, most states are very interested in achieving some system balance. Rebalancing is really a misnomer because the system is never balanced to start with, but really the health plans have also been effective partners in working with the nursing home industry and HCBS providers to build additional capacity for community based services; and the way they are paid, frankly in most states, gives them a financial incentive to try and serve individuals in the community, since that is the preferred and less expensive option.

Camille I-D: Third, the states are interested in proving the quality of their LTSS system and plans have a natural quality infrastructure that they can apply to long term services and supports. Plans also have, frankly, more flexibility to pay for services than states do. It’s a longstanding conundrum, but nonetheless, the health plans can use their capitated funds in a more flexible way that allows individuals to maybe get services that might not otherwise be available to them in the fee for service system. It also allows the person to be at the center of services. In other words, a system that’s both looking at not only their long term services reports, but also their acute care needs. We find that in many states, MLTSS programs have increased the number of older adults, of people with disabilities, that are getting preventive services when they have historically been underserved.

Camille I-D: Then last but not least, fee for service systems tend to be unpredictable as the state just continues to pay claims, sort of without knowing what’s going to be coming next. Managed care capitation payments do provide a measure of stability and predictability for a state Medicaid program, and we have found in a handful of states that have been doing this for a while that while Medicaid costs have not gone down, they never will probably go down, but they have in fact slowed the growth in per person costs that the state was facing in the fee for service system. So the appropriately deployed managed care can be a really effective tool for states to try and address both quality, innovation, as well as the growing demand for HCBS. Next slide.

Camille I-D: This is a snapshot of what the … where managed care for LTSS currently exists in the country right now. There are 24 programs that are either statewide or regional. Those include the financial alignment demonstrations, the capitated financial alignment demonstrations that were funded through the affordable care act. Right now, there’s not a lot of activity to move into additional states, but there are great opportunities in a number of the states in the Midwest, in the South, that have managed care programs for the TANF population and the low income adult population that could be moved … applied to LTSS programs. Next slide.

Camille I-D: I think that’s it for me. I’m going to turn it back to Kathryn.

Rachana Pradham: Great. Thanks so much, Camille. Now finally we’re going to have Maureen, who’s going to review the program of all inclusive care for the elderly, or the PACE program.

Maureen Hewitt: Hi, this is Maureen Hewitt. Thank you for allowing me to join today, and for including PACE as part of the discussion. It’s such an important one today. I’ve had the privilege of serving the organization for the last 12 years, and have intimately learned just how important this population is, and just how complex it is in developing the program that is really needed. Page two, please.

Maureen Hewitt: So our mission is to sustain and enhance the independence and quality of life for those we serve on their terms. We believe this is very key in our organization. We believe we’re committed to empowering seniors to really being their advocate, of creating their personal road map that they’re in charge of, and including their families. We’re a very consumer driven product, but we believe that the participant and member decides and is very formally involved in their care, and all of their evolving needs in the future. Page three.

Maureen Hewitt: So what is PACE? The Program of All inclusive Care for the Elderly, you may or may not know but it was actually developed in the 1960s, and it was part of the British day model and it came over to the United States in the 1970s and began in [inaudible 00:42:30], and was a very successful for PACE. It really is interdisciplinary team directed. That is the secret sauce around what does PACE do and why has it been successful for this group of seniors? It integrates both Medicare and Medicaid funds, and it’s completely focused on the entire person. We do a lot of work at InnovAge with the military and veterans, and we’re beginning to see that it is now reaching out past just the dual eligible, but to some of the private as well.

Maureen Hewitt: The wheel and spoke in the center of this document really describes everything from the medical care to social determinants of health. So when you think of some of the infrastructure of PACE, and what a lot of programs are trying to do, there’s the answer right here: coordinating healthcare, bringing transportation in, having in home assistance, managing the pharmacy piece, and all of the social engagements, and dental, and hearing. We even do some light surgeries as well on the dental front. It’s the preferred option to nursing facilities. We serve about 6400 PACE members, and about 9% of the people we serve are actually in a nursing facility. The growth with PACE, although it continues to grow through the United States, has been small when you think of the 2.1 million PACE eligibles that are out there in the world. There’s quite a group of people that need services. So currently it’s serving about 52,000 folks across the country or nationwide. Page four.

Maureen Hewitt: So PACE services are really broken down into every component: primary care, physicians, nursing services, our behavioral health team, our social workers, restorative therapies. We even do acupuncture, personal care, nutrition, meals, transportation, labs, x-ray. Everything goes on in that center. About the average of people come to the center about three and a half days per week. At InnovAge, we’ve developed larger centers to be able to scale within communities. We recognized early on that the smaller type centers were difficult to develop from an operational standpoint. Flexible in home support. What’s great about this program of bringing everything together medically and the social determinants is being able to do it, having flexibility, being able to go to a participant’s home, being able for them to come into the center when needing, having social activities. All of those things are just so important. We also do a lot of things from adding grab bars, wheelchair accessibility, putting ramps in the house, helping with laundry, walking the dog if needed. All of those things are really important. When you think about your age at this point, you’re 80 years old, about 69 to 70% of who we serve are females, often that they’re alone. So having that support, being able to wrap that around them is very nurturing, but at the same point really important when you think about their care plan and their utilization as well. Page five.

Maureen Hewitt: The impact on caregivers goes without saying. It’s such a toll on the family, both psychologically and economically. You can see that when a family member, and if any of you have ever taken care of your mom and dad, I certainly did and I know how difficult and challenging this can be for your family members. We know economically it’s about 25.5 annual loss in worker productivity; 13 billion additional employer healthcare costs for caregiving employees. So PACE helps reduce that burden. It just keeps the family together, and I often say we’re the bubble wrap around the families and around that participant that we serve. Page six.

Maureen Hewitt: So who’s qualified for PACE? They live in a PACE service area. It’s currently done by zip codes that are awarded. It is a three way party agreement between the state, the feds, and us as the provider. They have to be certified to a nursing home care, ability to live safely in the community with PACE support. 92% dually eligible for Medicaid and Medicare is the average. 75 years old. 69% are female. 31% are men, and 70% are living in the community. Top diagnosis, probably not surprising: diabetes, chronic complications, depression, COPD, chronic kidney disease, vascular. About 50% of our folks have dementia. Another 50, over 50% have either a primary and secondary psychiatric diagnosis as well. Another thing we’re seeing as time goes on is higher increase in substance abuse activities. Page seven.

Maureen Hewitt: So alternatives to PACE. You’ve heard about some of them today. Obviously PACE does a lot of great things, and so do some other programs. The dual institutional needs plans are out there that allow access for seniors to be part of those programs. The dual demo programs we’ve seen and heard about those. MLTSS was also mentioned, [ISWAY 00:48:28], and home and community based type services. When I really think about the volume of people with seniors that are out there, they’re not one program fits everyone. I think that’s something for hopefully our regulators and people to understand is that the people that we serve in PACE are certainly very frail. They are that 2.4 RAF score. They are the folks that need lots of assistance one way or another, and certainly couldn’t do it without having that framework and that infrastructure around them. There are other folks that are healthier dual eligible types of members and patients, and they do better in a less restrictive environment. So I think there’s a combination out there that needs to be part of the discussion that it’s okay to have that combination. Page eight.

Maureen Hewitt: We’ve heard this morning or this afternoon a lot about macro trends, and certainly PACE is that capitated model. I’m a firm believer in capitation and the capitated model. We know that we’ve had a lot of lack of coordination out there. There’s been failures of other programs; some of them due to economic failures, and some of them just due to not embracing consumer choice at the end of the day. We know that PACE has had support of both political parties on both the democratic side and the republican side. We know that we’ve saved some of the states and the federal government somewhere between 15 and 30%. Page nine.

Maureen Hewitt: So as I mentioned, there are about 2.1 million dual eligibles in the US that are estimated to be PACE eligible. We believe it is a great policy alternative to serve low income frail seniors and to deliver integrated acute care or long term care, and be able to do it well. I think that’s so important to people that are providers of care is to really do it well, and the risk model as well; and just putting all of those pieces together to serve that Medicare or Medicaid beneficiary. We know that PACE extends life for about a year or more, and there’s been a lot of discussion around that on extending life and what that means. But we also know that it reduces institutionalization, and it improves quality of care, and as I mentioned earlier, whole families together. We’ve had a long history of successfully providing community based high quality integrated care, and I think it’s something that other providers and people in need can learn from as well because they’re very important pieces of the PACE model that make it successful in really taking care of that frail seniors. There’s been numerous studies on PACE that have demonstrated positive health outcomes, and there needs to be more data and research on the cost saving nature of PACE as well. Next page, please.

Maureen Hewitt: So a little bit about InnovAge. We’ve been around since 1989. We’re actually about 6400 members served today. We operate in five states, soon to be six. We have 16 current PACE centers, and we are the largest currently in the country. We grow organically about 14%. Next page.

Maureen Hewitt: Here are the states we’re located in; in Colorado, six centers, California, we have one in San Bernardino, we have one under construction now in Sacramento, and we’re in a joint venture with the Adventist Health System, New Mexico, Pennsylvania, and Virginia. Next slide. Next slide, please.

Maureen Hewitt: Then here’s just some pictures of what our organization looks like and how our centers are developed from the bricks and mortar standpoint. We average about anywhere from 24,000 square feet to our largest in Sacramento, which is 68,000 square feet. So thank you very much for including me. To learn more, you can see come to www.MyInnovAge.com. Thank you.

Rachana Pradham: Great. Thank you, Maureen. Now we are going to turn to the question and answer portion of this meeting. Just as a reminder, you can still submit questions for all of our presenters today by typing them into the questions pane, which is located at the bottom of your control panel. So I’m just going to get us going by starting to … sorry, ask one question to the group. Could you all address how you see the issue of long term care progressing as the aging population continues to grow, and talk about the burdens that will continue to follow, and caregivers are how they might change as a result?

Anne Montgomery: Well, this is Anne. I’ll start off. That’s a great question, a very broad question. I do think that long term care from my perspective, maybe it’s because I’ve been looking at it for so long, and I’m so interested in it; but it will become more and more important as part of our healthcare system, really, because of the demographics that we were talking about in the shift toward a much older population … and also, of course, many younger people with disabilities are also living to old age as well; which is wonderful.

Anne Montgomery: So I think it just keeps growing, and we need to keep therefore creating expanded and more cost effective versions of what we already have, and also try some new programs of the sort that we were discussing earlier. We didn’t talk about some of the other ideas, and happy to do that. For example, I know that I think Kathryn was going to talk about a strategy to support catastrophic coverage, which is the tail end of long term care. I think we should definitely look at that as well. There’s a proposal out there from Mark Cohen, and then Judy [Fader 00:54:53], and Melissa [Favereau 00:54:54], if I’m saying her name right, that would basically put that in place, and the additional payroll taxes that people would pay would be pretty lean compared to what we’ve seen in the past. It seems like a great thing to look at. I don’t know that, that would be able to be implemented in time to help the boomer population, which is aging into Medicare as we speak.

Anne Montgomery: So there’s a variety of things, really, short term and intermediate term and longer term that I think we need to do. I think Jean and others express very, very well that the sort of default mechanism of having families and specifically those who are providing the care, family caregivers of their own free will, and out of their own generosity, simply cannot be the default at this point for many, many reasons. So we will need to support people more, but we … more than that, family caregivers more, we need to develop a more robust system of formal services.

Anne Montgomery: There’s one other thing I’ll say real quick, and that is that we could do more with volunteerism. There’s an interesting program out there that some of you may be interested in following. It’s not there yet, but it will be soon. It’s called the Community Care Corps. This is something that the Administration for Community Living is putting forward. They put out an agreement, a cooperative bidding agreement; and we are part of the team that won that. Effectively, it will stand up volunteer programs, or expand existing volunteer programs all over the country, of people who really want to give back to their communities, so it’s be very grassroots oriented; and with appropriate training, can go in and help people who are isolated, who are trying to age in place. They will not provide any medical care, any personal care. They will only do instrumental activities of daily living, but that is enormously important and something that I think we probably will not be able to field a large enough paid workforce to take care of people in that regard.

Anne Montgomery: So there are all kinds of answers. Those are just a few.

Jean Accius: Just to add on to what Anne just laid, I think there’s a couple of things, particularly at the federal level. We do have the RAISE Family Caregivers Act that was signed into law early last year, January 22nd of 2018, and directs the Secretary of HHS to develop, maintain, and updating national family caregiving strategy. That would include a couple of things. One is some of the things we’ve talked about today around greater adoption of person and family centered care, [instrument 00:57:31] assessment and service planning involved, that there’s respite options for family caregivers, and now we do have the RAISE Family Caregiver Advisory Council, which is advising the secretary of HHS on these issues … and is currently scheduled to sunset on January 22nd, 2021. But with the Dignity Aging Act, which was passed through the House of Representatives, which would re-authorize and extend the Older Americans Act, it also included some language around extending the RAISE Act, which would be extremely beneficial.

Jean Accius: On the state level, one of the things that has been exciting to see is a lot of passage around the Caregiver Advise and Record and Enable Act, which does three things. One is, in the case, it’s important to identify the family caregivers in the medical record. It’s important to ensure that the family caregiver has adequate notification of a discharge, and that the third, there should be training for the family caregiver if the care’s going to be dependent on that particular individual to provide care. This is in relations to performing medical nursing tasks. Again, as I indicated earlier around injections and wound care, and tube feeds, and the like. The great news is the fact that the Caregiver Advise and Record and Enable act, what we refer to as the CARE Act, which is a modeled piece of legislation that AARP championed, has been enacted in 43 states. We’re currently in the process of doing an environmental scan just to get a better understanding in terms of what is actually … how the states are implementing the act, and what are some of the promising practices. We hope to be able to provide some insight once we’re done with our environmental scan.

Jean Accius: Then, the other thing I would just quickly say is that we’re seeing growing momentum and support for paid family leave in the workplace. 60% of all caregivers are working in eight states and DC have or will soon have such policies. So I think that where there’s clearly challenges ahead, we’re seeing a lot of opportunity. Then finally, from a delivery system perspective, I think that we’re also seeing different types of models. We heard several on the call today. One I would just throw out there that I think is very innovative is the villages model, which is basically neighbors helping neighbors. It’s grassroots, and there’s over 300 villages in the US. There’s been some studies that have shown that those models are having a positive impact, particularly on quality of life, and also health outcomes.

Rachana Pradham: Very well. Actually Jean, that brings me to actually a question from one of our participants related to FMLA; which is … the question is, curious if anyone in the group has looked at the issue of FMLA, or the Family Medical Leave Act, of not protecting the job security of family members not in a parent/child relationship. I, an aunt and niece, who need to provide care to childless family members, but would not have any job protection via FMLA; if they needed to have a period of time where they weren’t at work to assist a relative.

Maureen Hewitt: This is Maureen with InnovAge. We have embraced that as part of our company culture of being able to help our family members. And matter of fact, many of the participants that are enrolled in our program, their sons and daughters work and are employed by InnovAge. But when people need to go, we … you can’t really walk the talk without doing some of that. Being able to help people take care of their families … Life is complicated at the end of the day. It’s just a complicated thing, and it’s busy. If you’re sandwiched between kids and parents, it becomes very complicated. Is there formal things that are written up on it in our organization? No, there are not formal, but I will tell you, we do practice it.

Jean Accius: This is Jean. One of the things I would just mention, in our scorecard, we actually incorporate it as one of the indicators around support for working family caregivers. What we found, we wanted to include some measure that looked FMLA by … and then showing that what states were going above the minimum requirements, particularly with regards to FMLA. What we found was the fact that nearly one fourth of the states … Again, this was around maybe 12 states, exceeded the FMLA’s floor of protections, with DC leading the nation with the most progressive coverage. We’ll be releasing the updated scorecard next year, and it’ll be interesting to see exactly where we are. But at least according from the time that we did this report in 2017, there were at least 12 states that exceeded the FMLA floor of protections with DC leading the nation.

Jean Accius: Then just to add on to what Maureen said, at AARP, we have in addition to sick leave and time off, that we have a caregiving leave benefit that allows staff to take up to two weeks to care for a family member or a loved one. They can take it at any point in time. They can take it consecutively. Then we also have a pool for a drastic situation where there may be a staff member who needs more assistance.

Anne Montgomery: Mm-hmm (affirmative). This is Anne. I would just add that there is some interesting legislation out there that folks might want to be aware of. It’s the Family Act. It’s been introduced in the House and the Senate, I think for several Congresses. It would essentially create paid leave for a range of people to help their parents, their spouses, their domestic partners, their children, also some other kinds of situations that it would cover; and effectively would build on some of the work that’s been done in several states, including California, to pioneer paid leave. You’d have employees and employers paying into a fund, and then you’d have an office administering the distributions. So it’s a really good step forward, I think, if we can get there. I don’t know what the prospects for it are, but it is definitely out there.

Anne Montgomery: To some extent, there is a move to sort of build on that idea in a proposal that the National Academy of Social Insurance has put forward in care across generations, and it’s called Universal Family Care. Those are essentially ideas to provide payments and other forms of support to … really across the lifetime to people who need that help, to help family caregivers. So that’s a particularly ambitious and very fascinating proposal; and I know they’re out there in the states talking to lots of people about it.

Rachana Pradham: Great. Thanks so much. I want to move on to one other question which is about state level policies. Can you all discuss, so what are some of the successful state level policies that we’ve seen from some of the above average states that potentially be translated into other states that have lower rates of HCBS spending? So what can be learned from those places?

Camille I-D: Hi, this is Camille. Well, some of it is sort of the approach that the state takes. A number of the states that are sort of leader states had a strong state funded infrastructure for HCBS before they expanded and started serving Medicaid patients, Medicaid consumers. You can only serve more people in the community if you actually have providers and capacity for it. Those states have been very creative in using shared living arrangements, allowing self direction for consumers to hire their own worker, care workers, potentially family members. So it’s a combination of a number of policies that have led to a infrastructure that works for those states.

Camille I-D: Honestly, I think in a number of states, the reason that those states are sort of lower on the list is the financing arrangements that states have in place for their Medicaid program through nursing home taxes and payments; and that’s a challenge to overcome for states that are challenged for to finance their programs through a general tax revenue. So that’s another barrier. It’s very, very complicated. I think each state’s structure is very unique. There are not a lot of policies that I think can translate from state to state, but they do spend a lot of time talking to each other certainly about coverage policies and those things that would make HCBS more readily available.

Anne Montgomery: Mm-hmm (affirmative). This is Anne. I would just say that Camille and I had the pleasure of being part of a round table a little over a year ago, that the National Governors Association put on. Out of that came, I think a very good paper, and you all might be interested in reading it. I’m sure it’s available on their website. It’s called “Improving the Health and Well-Being of the Nation’s Aging Population: Considerations for Governors.” So it really came out of a bunch of discussion between states and what they were doing to try to improve on what they have, which as Camille said, is really quite different from state to state.

Anne Montgomery: But there are some very innovative things going on. For example, Washington state has an 11-15 waiver that actually allows caregivers, family caregivers, to receive a narrow band of services to support them because they’re supporting somebody who otherwise would … who isn’t eligible yet for Medicaid, but who otherwise would be needing full time care, perhaps in a nursing home. So it’s a win-win for both the family who really doesn’t want to have their loved one necessarily placed too early in a long term care setting, and also for the state, which spends a lot less. So there are all kinds of very important things I think going on at the state level. I know advancing states is keeping up with all of those develops as well.

Rachana Pradham: So I wonder if we could just piggy back on that really quickly, and maybe Camille, you could talk about this for a second, which is Washington state this year became the first state in the country to create a state run long term care insurance benefit. There’s a question about whether other similar programs being considered by other states, or any bills or amendments, federal programs, that are being considered in Congress?

Camille I-D: Not that I’m aware of. I think as you could see from the AARP scorecard, and the Washington’s ranking on HCBS expenditures, they are a very progressive state in terms of taking on the challenges of the demands for HCBS; and then number of areas. As Anne mentioned, their TSOA program, this is only I think the latest attempt for them to really head face … take the challenge really head on. My understanding is that there are other states that have anything that look like this currently percolating, nor do I think there’s anything imminent on the federal level; but maybe either Jean or Anne might know that.

Anne Montgomery: I guess I would say … This is Anne, that yeah, I think Washington is out ahead, and maybe it has been for a while; but there are other states. We’re actually headquartered in Michigan. Michigan is one of those states that’s now doing a lot of thinking. There’s a study that they’re now engaged in, and we’re part of that. Some of my Michigan colleagues are gearing up to work on that. They’re going to look at public/private partnerships, and workforce. I think we’re doing the workforce piece. So they will come out with a plan in two years, I think, and try and figure out what to do with that plan once they’ve got it.

Anne Montgomery: So I think there’s a fair amount of that going on. I guess we should mention Hawaii for sure, which maybe took the lead, you could say, in pioneering a payment, a cash payment. I think it’s $70 a day for families who are supporting … caregivers who are supporting a loved one and need to cut back on work, perhaps, in order to do that. So I think we’ll see more and more. It’s probably early days, but I think states are going to try to be creative. There doesn’t seem to be a big federal bill that’s moving forward in that regard, not yet. I mean there are, of course, some interesting proposals. I don’t believe he’s introduced it, but representative Frank Pallone, now chairman of Energy and Commerce, had a bill out for discussion a year or so ago. So I know he’s thinking about this subject. [Ways and Means 01:11:28] just had a hearing last week, and the members were really very interested and very engaged, and particularly around family caregivers; and all of them have their own story about long term care and why it’s important to pay attention to it. It was remarkably bipartisan. That was very interesting. Some of the Medicare for all proposals have a long term care piece in them, so I take that as a sign of people are thinking about this even if they’re not ready to act right away.

Rachana Pradham: Great. One other question that we have here is for the group. Given the number, the high number of family caregivers and the value that they provide, would a tax incentive to these caregivers encourage more families to continue to provide that care to their relative?

Anne Montgomery: Do you want to take that one, Jean? I’m thinking.

Jean Accius: I was on mute. I know that there’s some states who actually looking at tax credits for family caregivers as we just talked about earlier, just giving the significant out-of-pocket cost that they are contributing in terms of just their own out-of-pocket costs, in addition to the value that they’re providing overall. I do think that there’s some merit to thinking about ways in which to provide some additional support, whether that is in the form of a tax credit or in some cases, respite care and some other benefits.

Anne Montgomery: Mm-hmm (affirmative), yeah. I’ll just say, and I think this is kind of noteworthy that we did a little bit of polling … I know AARP does a lot of polling, leading up in this case to the 2016 election. It was exit polling, so people had already voted when they talked to the pollsters. We bought a couple of questions in this poll, a national poll. The questions we wanted to ask were about direct care workers and family caregivers.

Anne Montgomery: So we had one question that said which of the following do you think would be most helpful for families who are supporting someone who’s ill, elderly, or disabled? There were three choices: financial help for family caregivers, so that could be a tax credit, for example, or a payment; easier access to care workers and in home services; making housing suitable for people with disabilities. There was not an option for all of the above, but that’s what people chose in great numbers. It was on both sides of the aisle, both republicans and democrats. So they volunteered that response. It wasn’t one that was given to them, and that’s unusual. The pollsters tell us people won’t usually do that.

Anne Montgomery: So I think what it tells us, and I don’t believe that’s probably changed, is that people know there’s a big problem out there and there are huge gaps. They want solutions, and they want solutions in many forms. They would welcome them.

Jean Accius: Absolutely. AARP has been very involved, particularly with the Credit for Caring Act, which would provide some financial support to family caregivers for many of the reasons why we talked about today. So it is an area of focus. We know that there’s some bipartisan interest, particularly around supporting family caregivers with some form of … with a tax credit. We look forward to helping to move that along.

Rachana Pradham: Great. Well, unfortunately we are running up against the amount of time that we have today. So I’m going to turn things back over to Kathryn to make some closing comments.

Kathryn M.: Great. Thank you all. Yes, thank you all for your engagement today and for submitting your great questions. I know we barely scratched the surface with this topic, but so the Alliance hopes to cover this long term care further in 2020. We’ll have to have our wonderful panelists and moderator back.

Kathryn M.: If you have time this afternoon, you’ll get an email later today with a brief evaluation. We really value your input. Definitely put comments about other topics, both in long term care or otherwise that we should be covering. For those of you that are in DC, we also have an in person briefing on a completely different topic on cell and gene therapies, so look out for that on December 4th. We’re also going to have a final webinar in our webinar series this year, likely on the Texas v. Azar decision if that comes out in the next couple of weeks as everyone is expecting; so look out for that as well. Then, finally as we do some planning for 2020, would love your thoughts, so please go to AllHealthPolicy.org and fill out our longer audience survey to give us some feedback on our programming.

Kathryn M.: With that, I will thank everyone again for joining. Thank you to our panelists and moderator, and that will end the broadcast.