Managed Long Term Care

1. Managed Long Term Care Robert Mollica March 2006

2. What is it? • A full or partial risk contract between the State Medicaid agency and a local government or non-government organization to provide specified services to one or more groups of Medicaid beneficiaries

3. Why do it? • Addresses needs that cross long term support, health and medical issues • Assigns responsibility and accountability for coordinating a range of health and long term support services • Reduces hospital, emergency room, and nursing home utilization • Improve consumer outcomes

4. Why? • Coordinates prescribing practices • Costs are more predictable for state agencies • Multi-disciplinary care coordination teams • Centralized record available to providers • Increases access to HCBS • WI Family Care eliminated waiting lists • FL program had more credibility with legislature and received additional “slots” • Capitation gives more flexibility than a “menu” of waiver services

5. Continuum of integration Disease management Primary care case management Partial integration Full integration

6. Challenges of dual eligible • Complex needs • Dual funding sources means different requirements • Limited commercial long term care experience • Extended provider networks & reporting

7. Dual eligibles - differences

8. Conditions

9. ADL impairments

10. Other differences

11. State priorities • Expand access • Create comprehensive, flexible benefit • End bias toward nursing homes • Simplify access and delivery • Reduce rate of expenditure growth

12. Target population Benefits Delivery system Approaches (1115, 1915 a, b, c – combination) Case management and coordination Capitation Quality assurance Major design issues

13. Population • All elders - nursing home & community • Medicare and Medicaid • Medicaid only • Nursing home residents • Nursing home eligible in community • Voluntary/mandatory

14. Benefits • Acute and long term care • Medicaid only • Medicaid and Medicare • Long term care only • Nursing facility and community care • Nursing facility only • Home and community based services

15. Arrangements Medicaid Medicare Acute MCO Fee for service Long term Fee for serviceCare

16. Alternative arrangement Medicaid Medicare Acute MCO A MCO B Long term MCO A care

17. Ideal arrangement Medicaid Medicare Acute MCO A MCO A Long term MCO A care

18. Medicare Special Needs Plans • Created by Medicare Modernization Act • Serve individuals with severe or disabling chronic conditions, dual eligibles, and/or individuals in institutions • SNP describes the population to be served and their capacity to serve them • 276 plans approved in 42 states • 226 serve dual eligibles • MI: Midwest Health Plan, Molina, Fidelis Secure Care

19. MI Olmstead coalition principles • Participant driven • Person centered planning; honor consumer preferences • Based on choice, equity and quality • Professional caregivers, services and supports • MCO maintains quality, accountability • Workforce is valued, compensated, trained • Supply of long term supports meets demand

20. Principles…. • Preserve and build on high performing community supports and networks • Maximizes resources available • Consider impact on existing community supports • Flexible, encourages innovation at the local level

21. Principles… • Should be: • Distinct from existing acute care system • Clear method of coordination with acute care • Clear financial and functional eligibility criteria • Not result in decrease in services currently available • Limit contracts to non-profit MCOs • MCOs do not provide direct services

22. Principles… • Financing has capacity to expand to address changing demographics • Rates based on independent actuarial review • Efficiencies enhance services and supports • State shares financial risk • Rates are adequate to support person centered planning • Limitations based on aggregate number • State has resources to monitor, evaluate and remediate when necessary

23. Principles… • All contracts: • Explicit responsibility for the quality of all services in their delivery or operations system. • Requirements for a state system to monitor and measure the quality of authorized and delivered services, an array of enforcement tools, including the ability to refuse payment if quality is not maintained or delivered. • A uniform, fair and timely appeal mechanism to appeal

24. Principles… • Independent entity to investigate critical incidents, allegations of abuse and neglect, and complaints • Requirement for MCO and contractors maintain an effective quality management plan • Incentives, consequences and sanctions ensure that the responsibility of state government for quality and accountability is vigorously pursued

25. Consumer perspective in NY • Broad and inclusive group to be served • Consumer protection, educational programs and ombuds services • Consumers/advocates involved in developing regulations and approving plans • Quality trumps cost containment • Meaningful public monitoring and evaluation of quality • Plans must be accountable to the state agency Nursing Home Community Coalition, 1999

26. Potential benefits • Coordinated services • Emphasis on preventive and community care • Savings for improved care (due to integration and Medicaid and Medicare) • Flexibility of resource utilization • Decreased cost • Accountability Nursing Home Community Coalition, 1999

27. Potential problems • Limits on care and quality • Inadequate provider capacity/poor quality providers • Lack of access to plans • Limits on outside specialty care • Incentives toward institutional care Nursing Home Community Coalition, 1999

28. Operating programs* Arizona Florida Massachusetts Minnesota New York Texas Wisconsin Developing new programs Florida Kentucky Maryland New Mexico Vermont Washington Who does it? * Not including PACE programs

29. ALTCS* 23,400 Star+Plus 10,600 MSHO 4,000 New York 7,000 Florida 3,000 WI Partnership 1,600 WI Family Care 7,000 MA SCO* 4,000 Enrollment (2004) * Statewide

30. Enrollment • Mandatory • Wisconsin Family Care* • Arizona Long Term Care System • Texas Star+Plus • Minnesota PMAP * Only program that covers HCBS

31. Enrollment • Voluntary • PACE • Florida Diversion program • Massachusetts Senior Care Options • Minnesota Senior Health Options • Minnesota Disability Health Options • New York Managed Long Term Care Plans

32. What’s included • All Medicare and Medicaid services • MSHO, MnDO, MA SCOs, WI Partnership) • Medicaid acute and long term services • Texas Star+Plus, MN PMAP • Long term services only • Wisconsin Family Care, NY, FL Diversion

33. Populations served • NF level of care PACE, ALTCS, FL diversion, NY MLTC WI Partnership • All beneficiaries MSHO, MnDHO, SCO Star+Plus

34. Populations… Elders only PACE, MSHO, FL diversion, MA SCO Elders/adults ALTCS, NY MLTC, w disabilities TX Star+Plus, WI Family Care Adults w disabilities MnDHOonly

35. Sponsors • Non-profit organizations 13% • For-profit organizations 70% • Local government 16%

36. Barriers • MCOs lack experience with long term supports • Long term supports providers lack experience with primary and acute care services • Difficult to build sufficient reserves to cover risk • Consumers don’t trust entities with a financial incentive to limit services • Existing providers/case management organizations fear loss of role/revenue • Fear that MCOs will leave the program and the LTS delivery system will be weakened

37. Two key questions • If you build it, will providers come? • Will consumers enroll in a voluntary program if there is not perceived expansion in benefits?