Health Plan Strategists: Fish Where the Fishes Is — in LTSS
One of the best pieces of advice I ever got in business was to “fish where the fishes is”, and for health plan strategists it holds up. In this Golden Age of Government-sponsored Health Programs, one of the biggest fishing holes is Long-Term Services and Supports, and a new primer from KFF lays out the opportunity beautifully. And the hazards: patients who require LTSS are of course the most vulnerable and complex patients in the entire US health system, literally the final frontier for health plans and coordinated care. Huge risk, huge rewards.
LTSS — often totally unfamiliar to both Medicare and Medicaid plans, and requiring new types of providers in-network — help the elderly and disabled with activities of daily living, and include nursing home care, adult day care, transportation, and caregiver supports. As a nation in 2012 we spent $368 billion on LTSS, 40% of that from Medicaid, and 20% from Medicare, and likely to be around $400 billion today. That’s way more than what we’re spending on ObamaCare’s exchanges and subsidies on an annual basis. It’s unsustainable already, and is now a top-2 item in most state budgets. And with seniors 85+ now the fastest-growing segment of the US population, and their needing LTSS at four times the rate of their younger cohorts, the urgency to convert these vulnerable patients to a coordinated care environment has never been greater, and it’s happening fast.
Most LTSS reforms occurring at the state level involve transitioning frail elders and the disabled from the human warehouses of nursing homes and rehab hospitals to home and community-based settings, often under a capitated financial arrangement. With a year of nursing home care costing $90,000+ but a home health aide or adult day care running about $20,000, it’s not hard to see why 45 cash-strapped states are pushing this transition.
The catch is that with the complexity of these populations, and the growing resistance of beneficiary advocates, especially for the developmentally disabled, this transition will involve an unprecedented degree of transparency and accountability from health plans. If you think Medicare Advantage Star Ratings measures are tough, you ain’t seen nothin’ yet. Many quality standards for the frail and disabled, like provider visit timeliness and drug adherence, haven’t even gotten off the drawing board yet, and they often vary by state. What’s clear is that service and coordination expectations of regulators will be far more robust for very old and disabled beneficiaries. That means more emphasis on data-driven case management and coordination, in-home and in-community interventions, robust reporting for regulators and actionable clinical intelligence for providers.
So strategists should “fish where the fishes is” and plan to participate in these groundbreaking programs — but come equipped.
This blog was originally posted on blog.gormanhealthgroup.com.
John Gorman: Under John’s leadership, Gorman Health Group has become the leading professional services and solutions firm for government-sponsored health care, providing thought leadership and expert strategic, operational, and technology-based solutions. Read more.
