Managed Long-Term Services and Supports (MLTSS): Opportunities and Challenges in an Emerging Market

Presented by Julie Hamos at the 2nd Annual CEO Roundtable on September 15, 2016

As more states enroll their seniors and people with disabilities in Medicaid managed care, implement dual eligible demonstrations projects, and expanded Medicaid to childless adults, there is a growing need for health plans to provide managed long-term services and supports (MLTSS). The new CMS Medicaid managed care regulations have strengthened the requirements for MLTSS, while states are making new demands on health plans for access to effective home and community-based services. This is a significant new and emerging market, but many states and health plans have relatively little experience with these new complex populations. Hamos' presentation covers MLTSS requirements of the new CMS regulations, trends in shaping MLTSS programs, and strategies for Medicaid health plans to navigate both the opportunities and challenges.

Transcript

1. Julie Hamos, Health Management Associates
2. Managed Long-Term Services and Supports: Challenges and Opportunities in an Emerging Market 47
3. Public Financing of Health Care • By 2030 most Americans will have publicly-financed health care coverage • Most or all states will adopt some type of Medicaid expansion • Boomer-related growth in Medicare will be near its peak • Managed care will be the dominant service delivery vehicle for both Medicaid and Medicare • Exchanges will have significant enrollment 48
4. By 2030, Four Public Programs Will Cover 210 Million or 59% of All Americans 71 91 93 99 54 62 72 82 10 14 22 25 2015 2019 2024 2030 Millions of Beneficiaries CHIP Medicaid Medicare Exchange Source: HMA, 2015 49 140 Million out of 321 Million (44% of Americans) 172 Million out of 332 Million (52% of Americans) 192 Million out of 345 Million (56% of Americans) 210 Million out of 359 Million (59% of Americans)
5. Public Financing in the US Health Care System • When nearly 60% of the population has public coverage, we will be nearing the end of a long ideological battle • Cost control will be within reach -- most spending will be controlled through public budgets • Efficacy, comparative effectiveness, performance measurement and many other concepts that have emerged in the public programs will rise in importance 50
6. The Opportunities for Managed Care Organizations In Medicaid 51
7. Managed Care Spending in Medicaid • Managed care spending in Medicaid has been growing rapidly • Of ~ $500 billion in total Medicaid spending for 2015, managed care spending is now approaching $200 billion • Moving complex populations to managed care will double this amount, i.e., add $200 billion to existing $200 billion of spending • This will include residual “conventional” TANF/ABD acute services, but will consist mainly of LTC, SPMI, and IDD 52
8. Residual FFS Spending 53
9. Expansion of MLTSS • There are ~ 4 million LTC users with Medicaid financing • LTSS spending in Medicaid is very substantial, currently $140 billion, mostly FFS • States have set the stage to shift most of this spending to managed care • This shift is occurring with extraordinary speed, i.e., it looks likely to have been largely accomplished within the next 5-7 years 54
10. Total Medicaid Spending ($450 Billion) Total LTSS Spending ($140 Billion) Est. MLTSS Spending ($33 Billion) Medicaid MLTSS Spending in Context, 2015 • Spending for LTSS represented around 31% of all Medicaid spending entering 2015 • For 2015, estimated annual MLTSS spending will top $33 billion, 23% of all LTSS, and 7% of all Medicaid spending Source: HMA Estimate 55
11. Anticipated Growth of Overall LTSS and MLTSS Enrollment Through 2030 • Overall users of LTSS in the Medicaid program are anticipated to increase by roughly 1 million (25% increase) from 2012 through 2020. • Another 1.2 million anticipated by 2030, as the over-65 population experiences significant growth. • MLTSS enrollment will more than double (613,000 to 1.6 million) from 2014 to 2017. • By 2020, likely to exceed 2.5 million MLTSS beneficiaries enrolled, nearly four times today’s enrollment. By 2030, MLTSS could top 4.6 million, more than seven times today’s enrollment. 0 2,000,000 4,000,000 6,000,000 8,000,000 2012 2014 2017 2020 2030 Projected Growth in Overall LTSS Users, MLTSS Total LTSS MLTSS Source: HMA Estimate 56
12. Anticipated Growth of MLTSS Spending Through 2030 • In 2014, 613,000 MLTSS beneficiaries account for $22.7 billion in annual spending. • By end of 2017, 1.6 million MLTSS beneficiaries anticipated to account for $56.4 billion in annual spending. • By 2020, more than 2.7 million MLTSS beneficiaries could account for more than $95 billion in annual spending. • By 2030, more than 4.6 million MLTSS beneficiaries could account for nearly $200 billion in annual spending. $0 $50,000 $100,000 $150,000 $200,000 2012 2014 207 2020 2030 Projected Annual MLTSS Spending through 2030 (in $millions) Source: HMA Estimate 57
13. And Now the Challenges… 58
14. MLTSS: Concept of Complexity • Members requiring MLTSS are fundamentally different from those health plans have served in the past • The nature, breadth, intensity and frequency of contact with the health care system is completely different, as well as level of resources required • Health plans will be challenged – and will be measured in improving outcomes 59
15. Serving Complex Members • Differences between members that health plans serve today and members needing MLTSS are dramatic: – Current members are often with health plan for relatively brief periods; MLTSS members can be with plan for life – Current members are usually episodic users of the health system; MLTSS members can use the system every day 60
16. Serving Complex Members Continued • More differences: – Current members are rarely subject of individual attention from the plan; MLTSS members require what amounts to an individualized, organized system of care – Current members use what are commonly understood to be health services; MLTSS members use many services that are not health services, but which are critical to their health 61
17. New Federal CMS Managed Care Regulations New CMS managed care regulations codify MLTSS policies from 2013: • Adequate planning and transition strategies for beneficiaries • Stakeholder engagement • Enhanced provision of Home and Community Based Services – community integration • Deliberative state planning process -- standards for readiness reviews • Consistent with federal laws -- including Americans with Disabilities Act 62
18. CMS Managed Care Regulations Continued • Alignment of payment structures with MLTSS programmatic goals – Triple Aim, performance-based incentives • Support for beneficiaries -- independent beneficiary support system for choice counseling • Person-centered processes -- ensure that beneficiaries’ medical and non- medical needs are met and that they have the quality of life and level of independence they desire 63
19. CMS Managed Care Regulations Continued • Comprehensive and integrated service package – including coordination and referral when services are divided between contracts or delivery systems • Qualified providers – network adequacy standards, qualifications and credentialing of providers, and accessibility of providers • Participant protections -- participate in efforts to prevent, detect, and report critical incidents • Quality -- MLTSS-specific elements in quality strategies 64
20. Challenges for Health Plans • Redesign outreach/engagement strategies to target member, family, caregivers • Offer more flexible array of services, including participant-directed • Redirect network development to reflect community resources • Allow transition period for changes • Provide advocates/ombudsmen • Pilot alternatives • Provide cultural sensitivity training for providers and care coordinators 65
21. Addressing Beneficiary Resistance • Frame change as next step in move away from institutionalization • Acknowledge differences between acute/clinical care and LTSS • When applicable, frame opportunity to address waitlists • Partner early and on an ongoing basis with stakeholders in designing services, care coordination training, and person centered planning • Focus on individual’s needs, preferences, goals • Consider inclusion of peer-based coordinators • Re-examine approach to prior authorization 66
22. Addressing Beneficiary Resistance Continued • A new way of thinking about health plan members: a lifespan perspective • A new framework for services to deliver: medical, social, nutritional, housing, employment • New intellectual assets: people and community partners who understand these populations • Innovative approaches to client outreach and engagement • New systems for tracking and measuring performance • New ways of assembling, organizing, and paying providers in new kinds of delivery systems • More oversight and accountability by state Medicaid programs 67
23. Challenges for MLTSS Providers • Many have been human service providers funded by government or foundation grants, operating in silos • Must join multiple health plans and provider networks: medical, behavioral health, LTSS • Must think outside walls: manage care transition among providers • Must analyze data to measure performance and health outcomes • Must adjust to multiple utilization controls, billing, other procedures • Will have to transition from fee-for-service to new value-based payments 68
24. Addressing Provider Resistance • Hold harmless through initial period of transition • Allow “any willing provider” during transition period • Articulate an understanding of differences in licensure/certification of these providers • Incentivize performance through ramp up period • Provide more extensive training, technical assistance and other forums for providers new to managed care • Have back up strategies for less sophisticated providers, including claims processing during ramp up • Assure claims systems fully tested for new types of providers • Pilot innovative value-based payment models with providers 69
25. Example of Value-Based Payment for One Community Provider • Community mental health provider entered into innovative contract with MCO (“case rate agreement”) for highest-cost Medicaid users with serious mental illnesses (e.g. repeated hospitalizations) • With new payments, provider was able to change its model of care • New model of care documented lower costs and better outcomes o 53% reduction in ER visits o 50% reduction in BH hospital admissions o 55% reduction in 30-day readmissions; 58% in 90-day readmissions o 63% reduction in overall BH inpatient costs • MCO expanded case rate agreement to all of its members served by the provider 70
26. Are You Ready for MLTSS? • Not every Medicaid managed care organization can or will pursue any or all of these opportunities • MLTSS will require a carefully planned program of investments to build the infrastructure • In economic terms, the scale of the opportunity is unprecedented In terms of timing, it is not too late, but it is not too early! 71
27. HMA Resources • HMAIS1 – Provides access to state specific data including state Medicaid profiles, enrollment data, RFPs, etc. – https://hmais.healthmanagement.com • HMA Weekly Roundup – Weekly update on what is happening in state Medicaid programs around the country – https://www.healthmanagement.com/publications/hma-weekly-roundup/ • HMA Webinar Series – A series of webinars on hot topics in health care – https://www.healthmanagement.com/news-and-calendar/ 1. Requires a subscription 72
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