Managed Long Term Care
description
Transcript of Managed Long Term Care
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Managed Long Term Care
Robert Mollica
March 2006
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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
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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
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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
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Continuum of integration
Disease management
Primary care case management
Partial integration
Full integration
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Challenges of dual eligible
• Complex needs
• Dual funding sources means different requirements
• Limited commercial long term care experience
• Extended provider networks & reporting
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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
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Conditions
20%
11%
22%
1%3%
5%
0%
5%
10%
15%
20%
25%
MR Mental illness Dementia
Duals Non-duals
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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
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Other differences
66
34 33
24
55
2418
20
10
20
30
40
50
60
70
Female Live alone ER NF
Duals Nonduals
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State priorities
• Expand access
• Create comprehensive, flexible benefit
• End bias toward nursing homes
• Simplify access and delivery
• Reduce rate of expenditure growth
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Major design issues
• Target population• Benefits • Delivery system• Approaches (1115,
1915 a, b, c – combination)
• Case management and coordination
• Capitation• Quality assurance
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Population
• All elders - nursing home & community– Medicare and Medicaid– Medicaid only
• Nursing home residents
• Nursing home eligible in community
• Voluntary/mandatory
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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
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Arrangements
MedicaidMedicare
Acute MCO Fee for service
Long term Fee for serviceCare
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Alternative arrangement
MedicaidMedicare
Acute MCO AMCO B
Long term MCO A care
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Ideal arrangement
Acute MCO A MCO A
Long term MCO A care
Medicaid Medicare
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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Enrollment
• Mandatory – Wisconsin Family Care*– Arizona Long Term Care System– Texas Star+Plus– Minnesota PMAP
* Only program that covers HCBS
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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
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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
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Populations served
• NF level of care PACE, ALTCS, FLdiversion, NY MLTCWI Partnership
• All beneficiaries MSHO, MnDHO, SCOStar+Plus
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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
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Sponsors
• Non-profit organizations 13%
• For-profit organizations 70%
• Local government 16%
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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
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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?