Senior Care Pharmacy Coalition and ATI Advisory Share New Analysis of Medicare Beneficiaries Demonstrating Common Long-Term Care Needs Across Settings

DATE: June 5, 2023

Research Confirms High Prevalence of Multiple Chronic Conditions, Multiple Daily Living Impairments, and Widespread Cognitive Impairments Among Medicare Beneficiaries Who Need LTC

WASHINGTON, JUNE 5, 2023 – The Senior Care Pharmacy Coalition (SCPC) and ATI Advisory (ATI) have released a new analysis finding that 75% of Medicare beneficiaries who need long-term care (LTC) live in the community, while only 25% live in nursing homes or assisted living communities. Nearly 60% of the community-dwelling population with LTC needs also have four or more chronic conditions and fill 10 or more prescription medications a year. The analysis also finds that Medicare spending reflects these high needs. For individuals living in the community, Medicare Parts A and B per capita annual spending averages over $20,000 and Part D averages over $7,000. 

SCPC and ATI are releasing a report, “Medicare Beneficiaries with LTC Needs By Setting,” which profiles Medicare beneficiaries with LTC needs across all care settings, including individuals receiving services at home, in nursing facilities, or in assisted living communities. The analysis defines LTC needs as receiving help with at least two CMS-defined activities of daily living (such as bathing, dressing or eating).

The report demonstrates the care complexity, diverse demographics, and outsize spending for Medicare beneficiaries who need long-term care regardless of the setting in which they live.

The complex health profiles of Medicare beneficiaries with LTC needs require a high level of coordination that is rarely available in home and community-based care settings. Currently, beneficiaries in nursing homes and other care facilities are guaranteed access to the clinical and specialized services LTC pharmacies provide, but those living in community settings usually cannot get these services primarily because Medicare Part D Prescription Drug Plans (PDPs) may not pay for LTC pharmacy services in community settings, which reinforces systemic biases toward institutional care.

“We hope these new findings help policymakers understand the need to remove legal barriers preventing universal access to essential long-term care services, particularly LTC pharmacy services,” said Alan Rosenbloom, President and CEO of SCPC. “The data clearly shows that all Medicare beneficiaries who need LTC services, regardless of where they live, would benefit from access to the highly coordinated clinical and specialized services LTC pharmacies provide.”

Key findings include:

Individuals with LTC needs living outside the nursing home setting represent a large and demographically diverse population:

– A total of 75% of Medicare beneficiaries who need LTC live in community settings, at home or elsewhere, live outside of nursing home or assisted living facilities.

– Enrollees dually eligible for Medicare and Medicaid programs (dual eligibles) make up three in 10 Medicare beneficiaries with LTC needs who live in the community or in assisted living.

Individuals with LTC needs have complex care needs:

– Most (58%) Medicare beneficiaries who live at home and need LTC have four or more chronic conditions compared with only 41% for those who don’t need LTC.

– Cognitive impairment, Alzheimer’s disease, and dementia are associated with LTC need, and especially with residing in a facility.

– Serious mental illness afflicts three in 10 Medicare beneficiaries with LTC needs in the community.

Individuals with LTC needs have many prescriptions at a time, across settings:

– Among Medicare beneficiaries with LTC needs, 30% have eight or more Part D prescriptions per day, compared to 15% of beneficiaries without LTC needs.

– Two-thirds (65%) of Medicare beneficiaries who live at home and need LTC fill 10 or more different prescriptions per year.

The LTC population incurs higher Medicare spending across Parts A, B, and D compared to beneficiaries without LTC needs:

– The average per-beneficiary-per-year (PBPY) Part A & B spending for Medicare beneficiaries with LTC needs ranges from $20,948 at home in the community to $32,808 in nursing homes, compared to only $7,507 for beneficiaries without LTC needs.

– Among Part D enrollees, the average PBPY Part D spending is $7,172 for Medicare beneficiaries with LTC needs in the community compared to $4,080 for those without LTC needs.

“Our data show that the majority of Medicare beneficiaries with long-term care needs live in the community, and also face complex and chronic medical conditions that require a lot of medical care and prescription medications,” said Anne Tumlinson, CEO of ATI Advisory. “Too often Medicare beneficiaries with complex care needs receive either no care coordination or rely exclusively on family caregivers to manage everything. One simple policy solution is to ensure that Medicare beneficiaries with long-term care needs who live in the community can access specialized long-term care pharmacy services without having to seek admittance to an institutional care setting.”

About Senior Care Pharmacy Coalition

The Senior Care Pharmacy Coalition (SCPC) is the only national organization exclusively representing the interests of LTC pharmacies, representing 75% of the sector overall. Its members operate in all 50 states and serve 850,000 patients daily in skilled nursing and assisted living facilities across the country. Visit seniorcarepharmacies.org to learn more.

About ATI Advisory

ATI Advisory is a healthcare research and advisory services firm dedicated to system reform that improves health outcomes and makes care easier for everyone. ATI guides public and private leaders in developing scalable solutions. Its nationally recognized experts apply the highest standards in research and advisory services along with deep expertise to generate new ideas, solve hard problems, and reduce uncertainty in a rapidly changing healthcare landscape. For more information, visit www.atiadvisory.com.