Muskie School of Public Service

1. States, Dual SNPs and Medicaid Managed LTC: High Complexity Limits Widespread Implementation Muskie School of Public Service Presented by Paul Saucier at the ACAP Medicaid Managed Care Policy Summit July 15, 2009 Washington, D.C.

2. Muskie School of Public Service Acknowledgements ASPE Series on Special Needs Plans and State Medicaid Programs (Prepared by Thomson Reuters under contract to the DHHS Office of the Assistant Secretary for Planning and Evaluation) Hunter McKay, Project Officer. Paul Saucier, Jessica Kasten and Brian Burwell, Co-authors. Thomson Reuters technical assistance to the Pennsylvania Office of Long Term Living, Integrated Care Initiative. Cutler Institute for Health and Social Policy

3. Why are states interested? • Increase value in large and growing area of state Medicaid budgets • Better cost predictability • Appropriate substitution • Better accountability/quality focus • Complement rebalancing efforts • Medicare provider decisions impact LTC • Win-win-win for consumers, payers, plans?

4. MMLTC Enrollment Growth, 2004-2008 2004 figures from Saucier, Burwell, and Gerst, 2005. 2008 figures updated by Saucier.

5. Many states have engaged in serious planning efforts • Arizona, California (selected counties), Colorado, Connecticut, Delaware, Florida, Hawaii, Maryland, Massachusetts, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Pennsylvania, Rhode Island, Tennessee, Texas, Vermont, Virginia, Washington, Wisconsin

6. 10 have implemented MLTC outside of PACE • Arizona, California (selected counties), Colorado, Connecticut, Delaware, Florida, Hawaii, Maryland, Massachusetts, Michigan, Minnesota, New Mexico,New York, Ohio, Oregon, Pennsylvania, Tennessee, Texas, Vermont, Virginia, Washington,Wisconsin

7. Half of states with SNP contracts have MLTC programs

8. Why haven’t more states included MLTC in their SNP contracts? • State capacity needs • Dual eligibility issues • Consumer and advocate perceptions of MCOs • Potential loss of position among HCBS stakeholders

9. State Capacity Needs(MMC Capacity not Sufficient) • Managing plans v. managing waiver slots, providers • Providing incentives v. direct role in building community capacity • Integrated care management v. waiver services management • Quality improvement v. assurances and incident reporting

10. Dual Eligibility Issues • Degrees of integration • Shifting federal policy

11. Purpose and Population Example

12. Marketing Example

13. Care management example

14. MIPPA meets Medicaid Source: Pennsylvania Office of Long Term Living, ICI Design Overview Draft

15. More Dual Eligibility Issues • Challenging for state to capture savings • Funding streams remain separate • Substitution occurs, but who captures the savings? • Difficult to explain, and volatile federal policy increases uncertainty for state

16. Consumer and Advocate Perceptions of MCOs • Paternalistic, medical model of care will roll back hard-won battles for social model, self-direction • Gatekeepers manage costs, not care • Big on margin, small on mission

17. Potential Loss of Position among HCBS Stakeholders • Who is managing waiver services today, and what will their role be tomorrow? • How will their relationship to state government be altered? • Is real partnership with MCOs possible?

18. Catalysts for MLTC • Clear and stable federal authority for integration and aligned incentives • Early stakeholder engagement, and partnership building over time • Explicit attention to consumer-centered approach • State infrastructure