Editor's Note: In late 2014, Manatt Health authored a paper titled The Future of MassHealth: Five Priority Issues for the New Administration with support from the Massachusetts Medicaid Policy Institute (MMPI), a program of the Blue Cross Blue Shield of Massachusetts Foundation. The paper explored how the incoming administration could strengthen MassHealth, the Commonwealth's Medicaid program and one of its largest healthcare insurers. It identified comprehensive long-term care reform as one of the highest-priority areas to address.

MMPI subsequently engaged Manatt to prepare a new report to lay out a vision for MassHealth long-term services and supports (LTSS) that is person-centered, integrated, sustainable, accountable and actionable—and presents options for Massachusetts policymakers to consider when tackling some of the most intractable challenges facing the LTSS system. Below is a summary of key highlights. Click here to download the full report free.


LTSS enables hundreds of thousands of people of all ages in Massachusetts to live with independence and dignity, participate in their communities and increase their overall quality of life. MassHealth, the Commonwealth's Medicaid program, is the largest payer of LTSS, spending nearly $4.5 billion on LTSS in 2015, representing nearly one-third of all MassHealth expenditures and 12 percent of the state budget. Although the demand for LTSS is projected to skyrocket, few people are aware of the likelihood that they will need LTSS in their lifetimes and few viable LTSS financing options exist beyond MassHealth.

The increasing demand for LTSS, rising costs and building pressure on the workforce, coupled with a care delivery system that is fragmented and lacks meaningful quality measures, create an LTSS system in Massachusetts that may be providing suboptimal care while creating serious budget pressures on the MassHealth program. In addition, the fragmented LTSS system is difficult to navigate and may be increasing avoidable hospitalizations and ER visits and replacing much-needed functional supports with more expensive medical interventions. While Massachusetts is widely recognized as a leader among states in healthcare reform, it is near the middle of the pack on LTSS system transformation.

Establishing a Quality-Driven, Affordable LTSS Strategy

Massachusetts has a unique opportunity to address these issues and become a bellwether state on LTSS transformation, as state policymakers and stakeholders are coalescing around LTSS reform. Not only have stakeholders unanimously identified LTSS reform as one of the top five priorities facing the MassHealth program, but demographic trends predicting increased LTSS demand and spending are also propelling LTSS closer to the center of MassHealth policy debates.

State policymakers are incorporating LTSS into broader discussions about MassHealth payment and care delivery reform. They are recognizing the interdependencies among medical care, LTSS, behavioral health services and social support services in promoting health and well-being for some of MassHealth's most vulnerable members.

To become a leader on LTSS reform, MassHealth must expand its long-standing Community First policy vision and establish a quality-driven, affordable LTSS purchasing and delivery strategy. Implementation of the strategy will require a multiyear commitment and should result in a system with the following features:

  • Person-centered. It identifies and provides the services and supports that people prefer and need in the locations of their choosing, is flexible to meet the diverse needs of diverse populations, and includes consumers and their families as integral parts of the care delivery team.
  • Integrated. It has an infrastructure in which provider systems, funding streams, financial incentives, administrative agencies, regulatory structures, and contractual requirements are aligned such that medical and nonmedical providers share information and work together to coordinate and deliver comprehensive care.
  • Sustainable. It employs purchasing strategies that encourage and reward high-quality, high-value care that ensures individuals receive the right care in the right place at the right time, thereby helping to support the long-term sustainability of the MassHealth program.
  • Accountable. It designates entities at both the state agency and the delivery system levels to be responsible for administering and managing the care of the LTSS population, actively monitoring provider and plan performance and quality, and continually engaging stakeholders via transparent and publicly available program and data analyses.
  • Actionable. It leverages technological solutions to collect real-time outcome, quality and safety information from providers, in order for the state and consumers to make more informed decisions and appropriately intervene to improve processes, performance and quality.

Achieving the LTSS System of the Future

The LTSS system of the future likely can be achieved through various models. The best vehicle, however, is one in which a single entity or network of entities assumes financial responsibility and performance accountability for coordinating and delivering comprehensive care to LTSS populations and is vigorously monitored by the state. Options include Medicaid Accountable Care Organizations (ACOs), Senior Care Options (SCOs) or One Care Plans, consortia of community-based organizations, partnerships among such entities or a combination of these approaches.

Regardless of the vehicle, community-based LTSS providers must be at its core, as they have the expertise to service diverse LTSS populations. Such an entity, particularly one paid through a risk-adjusted global or shared savings payment arrangement and accessing Medicare financing for dually eligible populations, will have more flexibility than providers in the current system to address people's needs creatively in a person-centered and cost-effective manner and coordinate physical healthcare, behavioral healthcare and LTSS.

To successfully design, implement and oversee this transformation, the Commonwealth must designate a senior health and human services official to be responsible and accountable for the LTSS system. It must also invest in hiring highly skilled contract management and analytic staff to vigorously monitor integrated care programs and hold them accountable for providing high-quality, effective and accessible care. In addition, the state must monitor the financial performance of contractors, particularly those taking on financial risk and/or reward to ensure effective stewardship of state and federal resources and instill a level of confidence that public dollars are being spent wisely.

To achieve this vision, the Commonwealth must address seven fundamental reforms:

  1. Drive integration of LTSS at the provider level
  2. Assess and learn from existing programs and data
  3. Identify and implement meaningful quality measures
  4. Improve access to LTSS
  5. Support informal caregivers
  6. Enhance direct-care workforce capacity
  7. Expand access to affordable housing with supports

In some cases, new investments or reallocation of existing resources will be required to achieve the most lasting and sustainable improvements.


MassHealth's mission is to "improve the health outcomes of our diverse members, their families and their communities by providing access to integrated healthcare services that sustainably promote health, well-being, independence and quality of life." To fulfill this mission, the administration must continue to engage stakeholders in developing LTSS purchasing and delivery system reforms that help create a person-centered, integrated, sustainable, accountable and actionable LTSS system that is fully aligned with the rest of the care continuum. Massachusetts has demonstrated its ability to lead in healthcare system reform and should continue to lead by taking on comprehensive LTSS reform and advancing its legacy of leadership and innovation.