Editor’s Note: In November 2016, the Centers for Medicare & Medicaid Services (CMS) approved a Section 1115 waiver extension request for MassHealth to implement programwide delivery system and payment reforms over the next five years. One of the waiver’s five goals is to “improve integration of physical health, behavioral health, long-term services and supports (LTSS), and health-related social needs.” To accomplish this goal, the waiver creates a Medicaid Accountable Care Organization (ACO)-based delivery system that offers three different ACO models—Accountable Care Partnership Plan, Primary Care ACO and Managed Care Organization (MCO)-Administered ACO—with varying degrees of financial risk and reliance on the existing MCO structure, which the state will retain.
In a new issue brief for the Blue Cross Blue Shield of Massachusetts Foundation, summarized below, Manatt Health prioritizes issues for consideration as ACOs and MCOs plan to integrate and manage comprehensive LTSS. These findings result from lessons learned from managed LTSS programs in other states, as well as from interviews with key stakeholders in Massachusetts. To download the full issue brief free, click here.
MassHealth, Massachusetts’ Medicaid program, is the largest payer of LTSS in the Commonwealth and administers a number of LTSS programs, some in conjunction with other state agencies. Only 14% of MassHealth enrollees utilize LTSS, yet they account for more than 30% of all MassHealth spending or about $4.5 billion annually. Individuals who utilize LTSS span the population and have diverse and complex care needs. Nearly half are elderly, and a third are nonelderly adults and children with disabilities.
Massachusetts and the nation as a whole are grappling with how to improve access to quality care for individuals who require LTSS while containing costs. States are increasingly covering LTSS through managed care arrangements, as well as shifting care away from institutional settings to the home- and community-based services (HCBS) that individuals and their families prefer. In fact, HCBS now account for 70% of all MassHealth LTSS expenditures.
Under the new Medicaid ACO structure created through MassHealth’s Section 1115 waiver extension, approximately 68,000 adults under age 65 and children who use LTSS in Massachusetts will be eligible to enroll in ACOs and MCOs. Those who enroll will access a comprehensive array of physical and behavioral health services and a limited number of LTSS currently covered by MCOs, such as short-term nursing facilities, home health services and durable medical equipment. All other LTSS will be provided on a fee-for-service (FFS) basis outside the ACOs and MCOs until year 3 or 4 of the waiver. All ACOs and MCOs, however, are required to work with competitively procured LTSS community partners (CPs) throughout the five-year waiver to identify people with the highest LTSS needs and actively manage their care.
By year 3 or 4 of the waiver, it’s anticipated that all ACOs and MCOs will assume financial responsibility for the full range of Medicaid-authorized LTSS. For the first few years, a new LTSS third-party administrator (TPA) will support the ACOs by performing LTSS utilization management, data analytics, quality reporting and other functions in conjunction with MassHealth. The TPA will continue these functions for Primary Care ACOs, even after they assume financial responsibility for LTSS, since the Primary Care ACO networks are based on the Primary Care Clinicians’ (PCC) plans’ FFS provider network. The Partnership Plan and the MCO-Administered ACOs, however, will assume the TPA’s functions when they assume financial responsibility for LTSS.
Four Priorities for ACOs and MCOs
As ACOs and MCOs prepare to assume financial accountability for LTSS by year 3 or 4 of the program, they must develop and build internal capabilities to serve individuals with LTSS needs. This will require adjusting their care delivery models, operational protocols and financial/rate development models. ACOs and MCOs also may need to adapt their enrollment protocols, clinical care and continuity of care policies, network adequacy standards, credentialing and contracting processes, information technology systems, and grievance and appeals rules. In addition, organizations will need to ensure they are in compliance with the new federal Medicaid Managed Care rules, which include specific protections for beneficiaries in managed LTSS programs.
Among all the changes that ACOs and MCOs will need to make to integrate LTSS populations successfully, stakeholders identify the following four priorities:
1. Cultural competency. Stakeholders identified the historical divide between medical and nonmedical models of care for those with LTSS needs as the single biggest barrier to integrating care successfully. Long-standing administrative, purchasing, provider and delivery system silos have created two parallel yet separate systems of care for people who have LTSS and non-LTSS care needs. To break down the silos, build trust, facilitate communication and coordinate comprehensive services, managed care entities and their contracted providers must understand the disability rights movement and culture, and be able to deliver culturally competent care that respects the diversity in clinical and functional care needs, language, beliefs, and behaviors of LTSS populations.
It is important to remember that members with LTSS often have broad care needs that extend beyond typical medical interventions and include the need to access social supports. ACOs and MCOs will have to work with CPs and the community to incorporate nonmedical interventions into members’ care management activities, which will provide higher-quality care and may produce savings.
2. Care management and utilization management. Another key consideration for ACOs and MCOs is how they will develop and implement person-centered care management processes, particularly during care transitions, for individuals needing LTSS. To avoid confusion, service duplication and substandard care for the member, ACOs and MCOs need to clearly define care management roles and responsibilities in their member and provider materials, as well as for each party involved in the care management process. Establishing clear roles and responsibilities includes acknowledging the important part nonmedical providers, including family caregivers, play in care management.
While provider and caregiver input is valuable, the care should ultimately meet the member’s goals and preferences, to the extent possible. Options counseling can provide information about the services and resources available and can help members and their families understand their choices, make informed decisions, and determine the next steps themselves. In addition, ACOs and MCOs need to consider how to structure their clinical policies for individuals requiring LTSS. They must identify which services can help keep members in the community and out of costlier settings—even if that involves higher upfront costs.
3. Technology. Stakeholders agreed that providing successful care management to individuals with LTSS needs often involves robust information sharing, including electronic medical records (EMRs) and quality reporting. ACOs and MCOs will need to navigate the complicated and expensive world of health information technology and health information exchange to establish clear and secure lines of communication with providers and CPs. ACOs and MCOs must assess gaps in communication and technology—which are commonplace among small LTSS providers that may still depend on paper records and faxes—and decide what new capabilities they will require and support.
4. Workforce. The LTSS workforce largely consists of direct care workers, such as home health aides, patient care assistants and nursing assistants, as well as unpaid family caregivers. Both the direct care workforce and informal caregivers are overworked and undersupported. In addition, community-based organizations report challenges in recruiting case managers and other staff who will be critical to supporting the integration and coordination of services.
As ACOs and MCOs prepare to care for those with LTSS needs, they must consider how to tap into, support and expand the LTSS workforce to meet the growing need for LTSS. They also may need to work with their contracted LTSS providers to help address low wages and promote clear career paths for direct caregivers, as well as to improve both financial and emotional support for family caregivers.
MassHealth has clearly signaled that integration and coordination of LTSS with other healthcare services is integral to furthering its healthcare delivery system’s reform. CMS’s approval of Massachusetts’ new waiver shows that both the state and federal governments are prepared to make significant financial and infrastructure investments to achieve greater integration.
ACOs and MCOs should take advantage of the three-to-four-year lead time they’ve been given to ensure they are fully prepared to care for their members with LTSS needs. Doing so not only will provide better and more appropriate care for members, but also will help ACOs and MCOs—and ultimately, the state—contain costs.