Manatt Health developed a new chart pack in partnership with the Blue Cross Blue Shield of Massachusetts Foundation, titled "MassHealth Matters II: Long-Term Services and Supports (LTSS) Opportunities for MassHealth." Findings from the chart pack were featured at an event hosted by the Blue Cross Blue Shield of Massachusetts Foundation on December 2, 2015. The chart pack, summarized below, examines the current state of LTSS, an area that MassHealth (Massachusetts Medicaid) identified as a priority for reform. Using previously unpublished LTSS data, the chart pack provides insights into MassHealth LTSS spending and utilization, access and affordability, workforce capacity, and quality, and includes a summary of opportunities to improve delivery and coordination of LTSS. To download a free copy of the full chart pack, click here.

What Are LTSS?

LTSS include a range of services that people with disabilities and chronic conditions use to meet their personal care and daily routine needs to promote independence, support their ability to participate in the communities of their choice and increase their overall quality of life. LTSS are delivered in a full spectrum of home, community and institutional settings across the care continuum. LTSS include: care coordination, transportation, homemaking, laundry/chores, meal preparation, day habilitation, durable medical equipment, adult day healthcare, personal care services, home healthcare, private duty nursing, physical therapy and skilled nursing care.

Why Focus on LTSS in Massachusetts?

1. People of all ages use LTSS to live independently in the settings of their choice. Estimates indicate that about 750,000 people—or 11% of the non-institutionalized population—report having a disability. Massachusetts' population is projected to age rapidly, with the rate of growth for those over 65 years of age expected to increase by 46% in 20 years.

2. Spending on LTSS accounts for almost one-third of all MassHealth spending and is expected to grow. MassHealth is the largest payer of LTSS in MA, with 2015 LTSS spending at $4.5 billion or 12% of the entire state budget. National estimates project the rate of spending growth for Medicaid LTSS to be more than three times that of Medicaid overall.

3. Massachusetts has expanded access to community LTSS, but there is more work to do to improve the delivery of care. Although Massachusetts has aggressively shifted LTSS utilization and spending to the community, institutional spending has yet to decline accordingly. While Massachusetts is testing several MassHealth managed care options that include LTSS, most people who use LTSS remain in a fee-for-service system. MassHealth funds many key programs, yet they are operated by various state agencies, resulting in a confusing and fragmented system.

4. There is an opportunity for Massachusetts to become a national leader. In a national ranking of states on 25 LTSS metrics, Massachusetts currently ranks 18th. It scored in the second quartile on affordability and access, choice of setting and provider, quality of life and quality of care, and ease of transitions. However, it only scored in the fourth quartile for support for family caregivers.

Who Uses MassHealth LTSS and What Does Spending Look Like?

Individuals who access MassHealth LTSS are a diverse group. Roughly 14% of MassHealth enrollees—or 251,000 people—currently utilize LTSS. Of those using LTSS, nearly half are elders and almost a third are adults and children with disabilities.

MassHealth is the largest payer of LTSS in the state, accounting for nearly half of all spending in 2010. In 2013, LTSS spending accounted for about 35% of all MassHealth spending, and that amount is expected to grow dramatically. While only 14% of MassHealth enrollees utilize LTSS, their spending accounts for nearly a third of all MassHealth spending.

How Has MassHealth Rebalanced Spending?

In 2008, MassHealth spending on community-based LTSS accounted for just 43% of MassHealth LTSS. As the state has aggressively focused on rebalancing efforts, the percent of LTSS spending on community-based LTSS grew to nearly 60% in 2013 and is expected to rise to 65% in 2015.

Over the last decade, MassHealth has made a concerted effort to rebalance LTSS and shift spending from institutional to home and community-based care. Between 2012 and 2015, per enrollee costs for MassHealth FFS community services increased 26.5% to $8,200 per person and FFS day/residential services increased 13.7% to $15,400 per person. Over the same period, spending on FFS institutional services dropped 2.3% to $31,200 per person.

Massachusetts remains a leader both regionally and nationally in providing home and community-based services. It ranks 9th overall in percent of Medicaid spending for home and community-based care.

What Issues Does the Workforce Face?

LTSS are provided by both formal direct service workers, such as Personal Care Aides (PCAs) and Home Health Aides (HHAs), and by informal caregivers, such as family members, close friends, and neighbors.

PCAs and HHAs are among the fastest growing jobs in the country, with estimates anticipating they will grow by about 70% in the next five years. Despite this expected growth, annual wages for PCAs and HHAs in Massachusetts are low—less than $27,000 a year. In 2014, PCAs and HHAs were among the lowest paid out of the 30 fastest-growing jobs. In June 2015, Massachusetts approved a new contract that aims to stabilize and support the personal care workforce by increasing hourly wages to $15 by 2018.

In 2015, a RAND study estimated that informal care for elders was more than $500 billion nationwide, larger than the entire current federal Medicaid budget. Massachusetts ranks near the bottom for supporting family caregivers. In 2013, family caregivers in Massachusetts provided 786 million hours of care, valued at almost $15 an hour. In total, it is estimated that the total economic value of care was worth $1.6 billion. Only two states provided a greater economic value of unpaid care per capita than Massachusetts.

What Are the Opportunities and Considerations Ahead?

Massachusetts can significantly advance the promise and goals of its person-centered "Community First Olmstead Plan" and become a national leader in LTSS by focusing on six opportunity areas:

1. System integration and navigation. Continue to better align and integrate the LTSS system, which is fragmented across several agencies, delivery systems, and programs. The current system makes it difficult for people to receive clear information and efficiently access LTSS.

2. Community-based LTSS access. Close remaining gaps in access to community-based LTSS by exploring additional Medicaid state plan and waiver options and dedicating sufficient resources to fully implementing the Balancing Incentive Program (a federal program that provides grants to 21 states to increase access to non-institutional LTSS).

3. Sustainable delivery system and funding reforms. Clearly define and articulate the role of community and institutional LTSS, major drivers of MassHealth program costs, with respect to the state's broader MassHealth delivery system and payment reform efforts.

4. Social determinants of health. Explore care delivery and reimbursement opportunities that integrate social determinants of health, such as affordable and accessible housing and medical transportation, with physical health, behavioral health and LTSS.

5. Workforce capacity to meet the growing demand. Dedicate focused attention and resources on providing supports to Massachusetts' nearly one million informal caregivers and sufficient wages to its direct service workers in both community and institutional settings.

6. LTSS quality improvement. Develop and utilize standardized LTSS quality metrics, as feasible, across state plans and HCBS waiver programs that measure care quality, safety and outcomes to help people remain independent and high functioning in their homes and communities.