Coordinating Managed Care and Long-Term Services and Support
Alexandria—In the United States, two-thirds of nursing home residents’ costs are funded by Medicaid. Although long-term care (LTC) patients account for 6% of Medicaid beneficiaries, they are responsible for almost half of the program’s spending. To minimize this cost, some states are looking to transfer Medicaid beneficiaries who live in nursing homes into a form of community-based care. If the transition of care is successful, it could decrease cost for states and improve quality of care for patients.
At the LSMMC meeting, Amy B. Bernstein, ScD, MHSA, policy director and contracting officer, Medicaid and Children’s Health Insurance Program Payment and Access Commission, and Patricia Packard, vice president, long-term services and support (LTSS), Amerigroup Florida, presented a case study on Florida’s managed care mandate for Medicaid beneficiaries and how it affected nursing home residents. They also gave an overview of managed LTSS programs throughout the United States.
Ms. Packard explained the approach Florida implemented to transfer beneficiaries to community-based care. Every Medicaid beneficiary was assigned a LTC manager who oversaw the process. By screening patients, LTC staff determined which patients were capable of successfully transitioning out of the nursing home by using a color-coded label for patients’ status: green indicated the patient was able to move to community-based care; yellow indicated the patient had the potential to leave the nursing home but required more time; and red indicated the patient did not have the ability to leave the nursing home despite supplemental rehabilitation.
For patients who were designated green, a comprehensive assessment was completed to ensure that they were ready for the transition. The proper documents were completed and weekly case conferences were held. A $2500 per-patient allowance was set aside for moving expenses. Patients in the yellow category were reassessed every 3 months until they qualified for the green category. Patients in the red category were reassessed in 3-month intervals to determine if they qualified for the yellow category. Some patients in the red category were deemed permanently unfit for transitioning.
Of the patients who left a nursing home facility, the majority did not transfer back into a nursing home, according to Ms. Packard. Most patients who enrolled in a nursing home were transferred out once their rehabilitation process was complete. Ms. Packard said, “We need to make sure before someone leaves a nursing home that they go through all the necessary physical rehabilitation.” Overall, the program successfully transitioned 4% of the population out of nursing homes.
Ms. Packard reviewed some of the challenges of transitioning Medicaid beneficiaries from nursing homes to community-based facilities. A lack of housing options caused difficulty when identifying a place where patients could transfer. The majority of eligible patients were discharged to assisted living facilities, while others were discharged to their own place of living or in the home of a caregiver. Another obstacle was motivating staff to continually evaluate patients, as Ms. Packard noted that it was easier for the LTC staff to keep patients in the nursing homes. The final challenge Ms. Packard mentioned was maintaining adequate care throughout the transition process. Care gaps could easily form when a patient transfers from 1 person’s care to another. “This is a very tough business,” said Ms. Packard.
Ms. Bernstein continued the session, noting that Medicaid managed LTSS (MLTSS) is an “up and coming thing,” as the number of states with MLTSS programs is increasing.
In late 2014, a study assessed 5 states’ MLTSS programs: (1) Arizona; (2) Florida; (3) Illinois; (4) New York; and (5) Wisconsin. The states were chosen for the analysis based on maturity of the program and system design features. The assessment identified 6 themes among the MLTSS programs.
One common theme was concern among beneficiary advocates regarding the potential for quality of care to decrease once Medicaid beneficiaries were out of the nursing home. Because each state varied in levels of development, some states did not have all assessment tools in place to determine if the level of care quality decreased. Ms. Bernstein said it was clear that an assessment of services is necessary for all states to ensure Medicaid beneficiaries are receiving adequate care. “Quality measures for LTSS are not as great as other areas,” said Ms. Bernstein.
The second theme was a clear need for quality measuring tools. More specifically, stakeholders said there needs to be a more efficient way to assess the quality of managed care organizations (MCOs).
Ms. Bernstein said another theme was Medicaid programs working with states to design MLTSS programs, although she mentioned the degree of legislative direction pertaining to each program varied. Another similarity was the LTSS program’s and MCO’s ability to influence the states to include or not include medical and other services in MLTSS benefit packages.
The fifth theme was that large MLTSS programs nor- mally had mandatory enrollment, which Ms. Bernstein said might assist states in minimizing adverse selection.
The final theme was that only 3 states obtained managed care plans competitively and limited the number of plans they contracted with. This strategy safeguarded the plans from failing due to lack of volume; the managed care plans could bear the financial risk, and made it easier for the state to assess each plan’s performance.
Ms. Bernstein closed the session by asking the au- dience questions pertaining to policy: “What lessons can be learned that will assist other states interested in implementing MLTSS? What quality measure would improve oversight of MLTSS programs?”—Melissa D. Cooper
