Long-Term Care Requires a Coordinated Long-Term Support Program

Arlington, Virginia—Providing long-term care (LTC) services to the aging population will become increasingly challenging as 76 million baby boomers approach retirement age. The Urban Institute estimates that 21 million of these individuals will require LTC services for daily-living activities by 2040, which is more than double the number of individuals requiring LTC services in 2000. This poses considerable challenges for many states, where Medicaid has already become the largest expense, making up, on average, ≥20% of states’ budgets. During the Medicaid Managed Care Summit, Katherine Eskra, vice president, Medicaid long-term care, Aetna, discussed efforts that are under way to help ensure that these LTC needs will be met, stressing the importance of developing and implementing coordinated longterm support programs, such as the Mercy Care Plan, which is Aetna’s Medicaid program. Recently, the US Department of Health and Human Services announced that it will provide states with $3.7 billion in new funding to provide alternatives to LTC institutional placements for Medicaid patients. Studies have found that states that commit to shifting from institutional care to home- or community-based services (HCBS) can save money over time. For example, Ms. Eskra noted that the Levin Group study found that “HCBS programs produced savings of $43 million in Colorado, $49 million in Oregon, and $75 million in Washington.” In addition, a 1997 review conducted by Laguna Research Associates, which examined the first 5 years of the Arizona LTC System (ALTCS) program expenditures, found a 16% average reduction in expenses compared with what traditional Medicaid would have cost. Ms. Eskra noted that not only would a shift to HCBS help states keep a handle on their budgets, LTC Medicaid recipients have been found to prefer plans that offer choices as to where they can receive LTC services, with the vast majority (87%) preferring to receive them in their own homes. In addition, those who have plans that support this flexibility and have received such services have given these plans high ratings. A member satisfaction survey from 2008 regarding the ALTCS program revealed that it was well received, with Aetna’s Mercy Care Plan, one of the program options, getting the highest scores countrywide. According to Ms. Eskra, this plan follows an integrated LTC model, which features a comprehensive member-centered approach. It covers HCBS services, offering a full array of support, from home modifications to access to durable medical equipment; acute services for nonduals and cost-sharing for duals; access to assisted-living centers, whether adult daycare, congregate care, or individual homes; and institutional care when necessary. In addressing factors that contributed to the success of Aetna’s Mercy Care Plan, Ms. Eskra outlined 3 main features: (1) the plan’s core philosophy, which is that its members have a right to choose where they live, with the plan’s objective being to provide the support needed to make this living arrangement possible; (2) a network of providers who understand the plan’s primary goal of keeping members in the least restrictive environments possible; and (3) case coordinators who have small case loads and who provide face-to-face visits with members, ensuring early assessment of individuals who are declining, enabling strategies to be devised to prevent these individuals from inappropriately entering nursing homes. In addition, the program provides members with access to nurse practitioners and physicians in members’ homes when needed; offers direct support to family members, which can include financial support in some cases; and supports a medical home concept, which rewards physicians for delivering high-quality care. The final point in Ms. Eskra’s presentation was that programs do not need to be integrated with Medicare to meet the objective of rebalancing home care with institutional care, as programs can tackle the cause of LTC placement without Medicare. Ms. Eskra noted that the main reasons many individuals end up in LTC institutional placements are dementia, functional decline in personal care, chronic incontinence, and lack of spouse or family involvement, all of which can be tackled through other support systems in the majority of cases.