Managed Long Term Care

Robert Mollica

March 2006

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

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

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

Continuum of integration

Disease management

Primary care case management

Partial integration

Full integration

Challenges of dual eligible

• Complex needs

• Dual funding sources means different requirements

• Limited commercial long term care experience

• Extended provider networks & reporting

Dual eligibles - differences

20% 20%

23%

10%

14%

10%

15% 16%

4%

7%

0%

5%

10%

15%

20%

25%

Stroke CHD Diabetes Brokenhip

Paralysis

Duals Non-duals

Conditions

20%

11%

22%

1%3%

5%

0%

5%

10%

15%

20%

25%

MR Mental illness Dementia

Duals Non-duals

ADL impairments

64%

8% 10%18%

90%

4% 3% 3%0%

20%

40%

60%

80%

100%

0 ADLs 1 ADL 2-3 ADLs 4+ ADLs

Duals Non-duals

Other differences

66

34 33

24

55

2418

20

10

20

30

40

50

60

70

Female Live alone ER NF

Duals Nonduals

State priorities

• Expand access

• Create comprehensive, flexible benefit

• End bias toward nursing homes

• Simplify access and delivery

• Reduce rate of expenditure growth

Major design issues

• Target population• Benefits • Delivery system• Approaches (1115,

1915 a, b, c – combination)

• Case management and coordination

• Capitation• Quality assurance

Population

• All elders - nursing home & community– Medicare and Medicaid– Medicaid only

• Nursing home residents

• Nursing home eligible in community

• Voluntary/mandatory

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

Arrangements

MedicaidMedicare

Acute MCO Fee for service

Long term Fee for serviceCare

Alternative arrangement

MedicaidMedicare

Acute MCO AMCO B

Long term MCO A care

Ideal arrangement

Acute MCO A MCO A

Long term MCO A care

Medicaid Medicare

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

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

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

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

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

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

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

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

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

• AccountabilityNursing Home Community Coalition, 1999

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

Who does it?

• Operating programs*– Arizona– Florida– Massachusetts– Minnesota– New York– Texas– Wisconsin

• Developing new programs– Florida– Kentucky– Maryland– New Mexico– Vermont– Washington

* Not including PACE programs

Enrollment (2004)

ALTCS*23,400

Star+Plus10,600

MSHO 4,000

New York 7,000

Florida 3,000

WI Partnership 1,600

WI Family Care 7,000

MA SCO* 4,000

* Statewide

Enrollment

• Mandatory – Wisconsin Family Care*– Arizona Long Term Care System– Texas Star+Plus– Minnesota PMAP

* Only program that covers HCBS

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

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

Populations served

• NF level of care PACE, ALTCS, FLdiversion, NY MLTCWI Partnership

• All beneficiaries MSHO, MnDHO, SCOStar+Plus

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

Sponsors

• Non-profit organizations 13%

• For-profit organizations 70%

• Local government 16%

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

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?