1

Managed Long-Term Services and Supports: The Potential for Medicaid Managed Care to Integrate Acute and Long-Term Care

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Webinar Speakers

6

Howard B. DegenholtzUniversity of Pittsburgh

Larry AtkinsLTQA

7

Kevin HancockPennsylvania Department

of Human Services

Patti KillingsworthBureau of TennCare

Camille DobsonNational Association of States

United for Aging and Disabilities (NASUAD)

8

Leigh DavisonAnthem

Paul SaucierIBM Watson Health

Merrill FriedmanAnthem

9Questions may be submitted at any time during the presentation

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Introduction and AgendaHoward Degenholtz andLarry Atkins

11Agenda

Topic Speaker

Overview Howard DegenholtzLarry Atkins

Overview of MLTSS Camille Dobson

State of the Science Howard Degenholtz

State Perspective: Tennessee Patti Killingsworth

State Perspective: Pennsylvania Kevin Hancock

Industry Perspective: Anthem/Amerigroup Merrill FriedmanLeigh Davison

Panel Discussion and Q & A Paul Saucier

Overview of MLTSSCamille Dobson

NASUAD: Who We Are

■ State Association: 56 members, representing state and territorial agencies on aging and disabilities

■ Our Mission: To design, improve, and sustain state systems delivering home and community based services and supports for people who are older or have a disability, and their caregivers.

Page 13

■ Our members include: State Unit on Aging directors Medicaid Long-term Services and Supports directors Developmental Disabilities Services directors

■ 11 staff manage Federal policy (congressional and executive branch), administer 6 Federal and Foundation grants, and publish Medicaid Integration Tracker and Friday Update

■ Convener of the National HCBS Conference – largest conference of its kind with over 1,400 attendees, 5 plenaries, 5 all-day preconference intensives and 110 sessions over 3 ½ days Page 14

NASUAD: Who We Are

What is Managed Long-Term Services and Supports (MLTSS)?

■ MLTSS is the delivery of long term services and supports (state plan, waiver or both) through capitated Medicaid managed care plans

■ Plans can be a managed care organization, pre-paid inpatient health plan, or a pre-paid ambulatory health plan (depending on scope of benefits provided)

■ In many cases, plans are covering medical services as well, which provides a comprehensive delivery system for beneficiaries

Page 15

Why MLTSS?

■ Accountability rests with a single entity Financial risk for health plan provides opportunity to

incentivize/penalize performance Plans can integrate siloed streams of care

(primary/behavioral/long term care) more effectively

■ Administrative simplification for state Eliminates need to contract with and monitor

hundreds/thousands of individual providers Managed care plans take on claims payment, member

management, utilization review, etc.Page 16

■ Budget predictability Capitation payments greatly minimize unanticipated spending Can more accurately project costs

■ Innovation and Quality MCOs can deliver services more flexibly than states They bring best practices from other states/product lines Demonstrated improvement in quality outcomes (HEDIS) over

FFS

Page 17

Why MLTSS?

Why MLTSS?

■ Consumer becomes the center, not their services LTSS interventions can lower acute care costs

■ Shift focus of care to community settings Most consumers express preference for community-based

services Health plans may be able to effectuate transfers from

institutions to community more easily

Page 18

It’s about this….

Page 7

Disabled 34%

Children 19%

Adults 32%

Elderly 14%

Disabled 13%

Children 43%

Adults 36%

Elderly 8%

Enrollment Expenditures

Nearly half of Medicaid spending is for the elderly and people with disabilities, FY2015

Source: Center for Budget and Policy Priorities

Page 20

And this…….

■ Older adults and persons with disabilities are disproportionately served in nursing homes rather than in community settings1

National average: 56.2% in NFs Pennsylvania: 67.8% in NFs

■ Consumers overwhelmingly express preference for community residence over institutional settings

1 Truven Health Analytics, Medicaid Expenditures for LTSS, FY2015, http://tinyurl.com/ydergz9ePage 9

And this.

MLTSS Programs - 2010

Page 10

MLTSS Programs - 2018

Page 11

Key Elements for an Effective MLTSS Program

Consumer/Provider Support

Rigorous RFP and Contract

State Oversight Capacity

Stakeholder Engagement

Thoughtful Program Design

Page 12

■ MLTSS continues to be the biggest trend/opportunity for states to address accountability, cost efficiency and better outcomes for consumers

■ Expansion of existing programs either statewide or beyond dual eligibles

■ Inclusion of LTSS services for individuals with intellectual/developmental disabilities in MLTSS programs Currently only IA, KS, and TN use commercial MCOs to

deliver these services

Page 25

Trends for 2018 and beyond

■ Focus on quality ■ States without managed care capacity or unwillingness to

implement or expand acute care managed care looking at partial-risk alternatives (ACOs, PASSE)

■ States also looking at expanding pay-for-performance/value-based purchasing from NFs and other large providers to HCBS providers

■ More and more involvement by MCOs in states’ Olmstead plans, as well as housing and employment first initiatives

Page 26

Trends for 2018 and beyond

■ Quality and cost are inextricably linked. Improved quality outcomes will reduce costs

■ Managed care is a set of tools and principles that can help improve coordination, quality and cost-effectiveness of care for the most complex populations It is up to the state to wield that tool in the most effective

way■ Implementing managed care well requires a significant

investment in the State’s capacity to ‘manage’ managed care plans It requires different skill sets and an accountability mindset

Final Thoughts

Page 15

■ It takes time to implement managed care well. Moving too quickly will undermine the success of the

program State should continue to get stakeholder feedback to make

continuous improvements to the program

■ It takes time to realize savings from managed care. Focus on short-term savings imperils long-term sustainability

of the program

Page 16

Final Thoughts

State of the ScienceHoward B. Degenholtz

30Examining the Evidence

• MLTSS authorities have implications for the degree of financial integration Alignment and care coordination

• Evidence from peer review and ‘grey’ literature• National Evaluations of FAI Demonstrations and 1115 Waivers• Summary

31

PhysicalHealth

PhysicalHealth

LTSS

BehavioralHealth

Medicaid Only

Degree of Financial IntegrationSingle

Corporate Sponsor

MedicaidMLTSS

Medicare D-SNP

MedicaidMLTSS

Medicare D-SNP

Medicare Advantage

Medicare FFS

Medicaid MLTSS

MedicaidMLTSS

Medicaid MLTSS

Full-Benefit Dually-Eligible

Single Combined

Plan

Medicare and

Medicaid

Integrated Fragmented

PACE, MSHO, Financial Alignment Demonstration

States can use MIPPA Agreements to Leverage Coordination

• States use 1115 or 1915 Waivers to Integrate LTSS w/Physical Health

• Behavioral may be included• Selected Populations

32

PhysicalHealth

PhysicalHealth

LTSS

BehavioralHealth

Medicaid Only

Coordinating Care CoordinationSingle

Corporate Sponsor

Medicaid MLTSS

Medicare D-SNP

Medicaid MLTSS

Medicare D-SNP

Medicare Advantage

Medicare FFS

Medicaid MLTSS

Medicaid MLTSS

Medicaid MLTSS

Full-Benefit Dually-Eligible

Single Combined

Plan

Medicare and

Medicaid

Single Care Coordinator

Separate Medicare and Medicaid Care Coordinators

Medicaid Care Coordination OnlyPeople May have separate BH Care

Coordinator

33Minnesota Senior Health Option

• Stream of journal articles and a recent ASPE/RTI/Urban report• Design:

• MSHO is an optional integrated Medicare-Medicaid program for duals compared to • MSCO is a mandatory managed care program for Medicaid Only (Senior Care Plus)• Limited to age 65+

• Findings:• Fewer hospital stays for community dwelling and nursing home residents• Fewer preventable hospitalizations and ED visits• More PCP visits• No difference in mortality• Early study found no substantial differences in function, satisfaction or caregiver burden• Recent study finds greater PREVALECE of HCBS But similar long-term nursing home use

– But no measure of quantity of HCBS• Caveat:

• Recent analysis had limited data on casemix, HCBS use, demographics, or dual status • Selection bias present

34Massachusetts Senior Care Options

• Design• Aged duals enrolled in SCO – a single plan for Medicaid and Medicare

– Voluntary– Limited to specific counties

• Compared to duals in Medicare FFS (in community or NF)• Findings:

• Decreased use of Skilled Nursing Facility• Delayed nursing home placement• No effect on hospital readmissions (Jung et. al, 2016)

• Caveats:• Data are from one participating SCO plan (50% of market)• Time period was 2007-2009• No baseline prior to SCO• Selection

35California - CalMediConnect

• Design• Optional Financial Alignment Demonstration in selected counties• Comparison groups are consumers who opt-out and those in matched

counties• Findings:

• High opt-out rates• Participants report higher satisfaction, access to care coordination, use of

HCBS compared to opt-out and comparison counties• Caveats

• Results so far are self-report; not adjusted; potential for selection• Outcome analysis is pending

36States Reporting Positive Impact

Budgetary Goals Quality of Life and Health Outcomes

Rebalancing Inpatient and ED Use

Arizona + +

Florida + + +

Iowa

Kansas + +

Massachusetts + + +

Minnesota + + +

New Jersey +

New Mexico +

Rhode Island

Tennessee + + +

Texas + +

Sources: Demonstrating the Value of Medicaid MLTSS Programs. MLTSS Institute. Survey of state informants conducted December 2016 to January 2017.The Value of Managed Long-Term Services and Supports. National MLTSS Health Plan Association.

37Financial Alignment Demonstration (RTI)

• National evaluation of 10 state programs using FAI Authority• Mixed methods:

• Stakeholder Interviews• Focus groups• Claims and Encounter data

• Comparison groups• In-state where possible• Out-state based on matching

• Separate state level studies• Early findings:

• Participation rates are low: only 27% of eligible people were enrolled due to opt-out and disenrollment (Grabowski et. al, 2017)

381115 Waiver Evaluation (Mathematica)

• National evaluation of transition to MLTSS• Descriptive analysis of trends• Analytic analysis of ‘effects’

• Analytic focus is on states that had programs by 2016• Transition to managed care occurred during 2009 to 2013• Submitted Medicaid Analytic eXtract (MAX) data• Had submitted FFS claims for HCBS services prior to MLTSS transition• Data quality checks limited sample to two states:

– New York & Tennessee• Analysis will compare MLTSS transition to neighboring states using difference-in-

difference models• Descriptive findings:

• Six states out of 7 reduced or eliminated waiting lists• Policy tracking of target populations, any willing provider rules, payment policies, level of

care determination, etc.

39Challenges

• Few studies are in peer reviewed publications• Limited data on quality of life or satisfaction

• New CMS requirements to collect participant experience data

• New measurement tools are available– CAHPS-HCBS; National Core

Indicators; NCQA• Limited pre-implementation data on participant

experience or cost• Weak comparison groups

• California compares enrollees to people that opt-out

• Massachusetts compares enrollees to fee-for-service

• Minnesota compares two different programs to one another

• Cost analysis is complicated• Limited to Medicare FFS• Different populations may be combined

• Programs cover multiple populations• Dual Eligible (no LTSS)• Long-Term Services and Supports Users

– Nursing Home Residents– HCBS Waivers

• Aged/Disabled• Acquired Brain Injury• Intellectual

Disability/Developmental Disability

• Programs have multiple outcomes:• Participant experience• Quality of life• Rebalancing• Utilization• Cost/Budget predictability• Employment and Community Integration

40Summary

• There have been few peer review studies on MLTSS programs:• No pre-program baseline data• Weak comparison groups• Voluntary programs introduce selection

• Evidence suggests that in the aggregate:• No harm• Some shift toward HCBS• Programs meet cost goals, but limited evidence of significant savings• Voluntary programs have low uptake

State Experience: TennesseePatti Killingsworth

• TennCare managed care demonstration began in 1994• Operates under the authority of an 1115 demonstration• Entire Medicaid population (1.4 million) in managed care since 1994 (including dual

eligibles and people with disabilities)• Three NCQA accredited health plans (MCOs) operating statewide (2 with LTSS distinction)• All required to have companion D-SNP (1 FIDE plan)• Physical/behavioral health integrated beginning in 2007• Managed LTSS began with the CHOICES program in 2010

• Older adults and adults with physical disabilities only• ICF/IID services and 3 Section 1915(c) waivers carved out;

operated by State I/DD Department (people carved in for physical and behavioral health services)

• New MLTSS program for individuals with I/DD began July 1, 2016: Employment and Community First CHOICES

Service Delivery System in Tennessee

The Growth of MLTSS

Source: NASUAD.org

The “Promise” of MLTSS

Source: TruvenHealth—modified

Better Experience Coordination of services; integration with primary, acute, and behavioral

Better Outcomes Health, function, quality of life

Flexibility Ability to tailor unique services/supports

Predictable, Managed Costs Budget stability and trend management

Alignment of financial incentives Pay for quality and value

Expanded access to HCBS The potential to provide services to more people and for increased flexibility in service provision—if done “right”

System Balancing Increase use of community services and decrease inappropriate use of institutional services

The “Promise” of MLTSS

We must not promise what we ought not, lest we be called on to perform

what we cannot.—Abraham Lincoln

The LTSS System in Tennessee before…• Fragmented—carved out of managed care• Limited options and choices• Heavily institutional; dependent on new funding

to expand HCBS

_________________________________________________________________________

Restructuring the LTSS System: Key Objectives• Reorganize – Decrease fragmentation and improve coordination of care• Refocus – Increase options/expand access to HCBS• Rebalance – Serve more people using existing LTSS funds, create a more

sustainable system

FY 1999

< 1% HCBS

FY 2009

~ 10% HCBS

HCBS.74%

Nursing Facilities90.68%

Nursing Facilities99.26%

HCBS9.32%

• Nursing facility services and HCBS for older adults and adults with physical disabilities integrated into existing managed care programo People do not enter/leave managed care or change health plans when enrolling in

LTSS• Blended capitation payment for all physical, behavioral and LTSS• MCOs at full risk for all services, including NF (not time-limited)• Enrollment target for HCBS supports controlled growth while developing community

infrastructure to provide care (persons transitioning from a NF and certain persons at risk of NF placement exempt)

• Cost and utilization managed via individual benefit limits, levels of care (LOC), and individual cost neutrality cap o Higher level of care standards for NF services, access to HCBS for “at-risk”

• Nursing facility diversion and transition programs, including Money Follows the Person Rebalancing Demonstration with incentive structure

Program Design Choices to Accomplish Objectives

• Objective #1: Expand access to HCBSo # receiving HCBS versus NF services

(point in time and unduplicated across the year)• Objective #2: Rebalance LTSS spending

o Total HCBS versus NF expenditures• Objective #3: Provide cost-effective HCBS as an alternative to

institutional careo Average per person NF versus HCBS expenditures

• Objective #4: Delay or prevent institutional placemento Average length of stay in HCBS o Percent of new LTSS members admitted to NFs

• Objective #5: Facilitate transition from NF to HCBSo Average length of stay in NFo # NF-to-community transitions

Baseline Data Plan to Measure Program Outcomes

Access to HCBS before and after…

0 1,131

4,861

13,240

6,000

02,0004,0006,0008,000

10,00012,00014,00016,000

HCBS

Expanded access to

No state-wide HCBS alternative to NFs available before 2003.

CMS approves HCBS waiver and enrollment begins in 2004.

Slow growth in HCBS –enrollment reaches 1,131 after two years.

HCBS enrollment at CHOICES implementation

Well over twice as many people who qualify for nursing facility care receive cost-effective HCBS without a program expansion request; additional cost of NF services if HCBS not available approx.$250 million (federal and state).

HCBS

Enr

ollm

ent*

•Global budget approach:

Limited LTSS funding spent based on needs and preferences of those who need care

More cost-effective HCBS serves more people with existing LTSS funds

Critical as population ages and demand for LTSS increases

* Excludes the PACE program which serves <300 people almost exclusively in HCBS, and other limited waiver programs no longer in operation.

HCBS waiting list eliminatedin CHOICES

Expanding HCBS; system balancing

Keeping the “Promise“ of MLTSS

HCBS17%NF

83%

LTSS Enrollment before CHOICES (March/August 2010)

• # of persons receiving HCBS in CHOICES increased by nearly 170% in first 5 years (from 4,861 to 13,240, as of 6/30/15); HCBS enrollment 12,381 as of 6/30/17

• # of persons receiving NF services in CHOICES has declined by nearly 6,500 people (from 23,076 to 16,597, as of 6/30/17)

• %age of people coming into LTSS in a NF declined from 81.34% in the year preceding CHOICES implementation to less than 50% during FYs 2013, 2014, and 2015, with more than 50% of people choosing HCBS upon enrollment in CHOICES for 3 consecutive years

• More than 3,500 individuals transitioned from NFs to HCBS as of 6/30/16, an average of almost 600 per year, compared to 129 people in the baseline year immediately preceding CHOICES

CHOICES Outcomes

Opportunities to Improve delivery of IDD Services

Tennessee spends nearly

2xthe national average per person for this population

3% of TennCare members

Account for 50% of total program costs

$1.2 billion

That’s

$936 millionServes 30,300 people who are elderly or have physical disabilities in TennCare CHOICES

Serves just 8,800 people who have intellectual disabilities

$40,000per person

VS$106,000

per personRe

ceivi

ng S

ervic

es

Wai

ting L

ist

7,800 6,200CHOICES Program ID Services

Significant gap between people with ID who want to work and those who are actually working

Little coordination between physical and behavioral health services and long term services and supports (LTSS)

Almost as many people on the waiting list to receive HCBS as those actually receiving services

Fragmentation:

Increased Demand for Services:

Cost:

Insufficient Employment Opportunities:

People with developmental disabilities not eligible for HCBS

• New MLTSS program component for individuals with I/DD integrated into existing managed care program o HCBS only; ICF/IID services and 1915(c) waivers remain carved out

• Enrollment target supports controlled growth while developing sufficient community infrastructure to provide services (persons transitioning from a NF and certain persons at risk of NF placement are exempt)

• People with employment-related needs/goals prioritized for enrollment• Cost and utilization managed via individual benefit limits, levels of care (LOC)—institutional/at-risk, and

expenditure (including individual cost neutrality) caps • Tiered benefit structure based on needs of people in each group provides comprehensive and flexible

service array, designed to promote employment, community integration, and individual/family empowerment

• Array of 14 employment services create a pathway to employment, even for people with the most significant needs

• Value-based reimbursement for employment services focused on achieving employment outcomes, and incentivizing fading (independence) over time

Program Design Choices to Accomplish Objectives

• Objective #1: Expand access to HCBSo # of individuals receiving HCBS

(point in time and unduplicated across the year)• Objective #2: Provide more cost-effective HCBS as an alternative to

institutional careo Average per person LTSS expenditures

• Objective #3: Continue balancing LTSS spendingo Total HCBS versus ICF/IID expenditures

• Objective #4: Increase competitive, integrated employment• Objective #5: Improve quality of life

Baseline Data Plan to Measure Program Outcomes

• More people with I/DD enrolled into HCBS in the last 20 months than in previous 6 years• For the first time in the State’s history, people with DD other than ID have access to HCBS • 87% of people enrolled in an employment-related priority category• Annualized cost of HCBS less than half the current average• Most frequently utilized services include (in order) Employment, Community Integration

Supports, Personal Assistance, Independent Living Skills Training, Respite, Community Transportation

• Memorandum of Agreement with Vocational Rehabilitation operationalized through statewide joint training of VR and MCO staff; regional implementation calls

• Over 20% of working-age individuals with I/DD working in competitive integrated employment (7% higher than national average with most people enrolled less than a year)o Average wages $8.48/houro Average hours worked 17 per week

ECF CHOICES Outcomes

• Are states defining clear policy goals for MLTSS?• Do states define clear measures and collect data

(including baseline) to know if they are achieving goals?• Can we measure/demonstrate the value of MLTSS?

• For states; most importantly, for beneficiaries• Does the level of integration impact quality and cost-effectiveness outcomes? • Is “real” integration happening?• How well are MLTSS programs addressing social determinants of health—coordinating services and

supports?• How do people with the most complex needs fare in these programs?• Are there replicable models (or components) of success? • What capacities do health plans need to provide MLTSS? • How capacities do states need to develop and oversee MLTSS?• How is MLTSS changing the face of managed care?

Some Key Questions

State Experience: PennsylvaniaKevin Hancock

Pennsylvania’s Recent MLTSS Launch:Design Components and Lessons

Learned

May 3, 2018

Kevin HancockDeputy SecretaryOFFICE OF LONG-TERM LIVINGDEPARTMENT OF HUMAN SERVICES

WHAT IS COMMUNITY HEALTHCHOICES (CHC)?A Medicaid managed care program that will include physical health benefits and long-term services and supports (LTSS). The program is referenced to nationally as a managed long-term services and supports program (MLTSS).

WHO IS PART OF CHC?• Individuals who are 21 years of age or older and dually eligible for Medicare and Medicaid.

Individuals with intellectual or developmental disabilities who are eligible for services through the Office of Developmental Program will not be enrolled in CHC.

• Individuals who are 21 years of age or older and eligible for Medicaid (LTSS) because they need the level of care provided by a nursing facility.

This care may be provided in the home, community, or nursing facility.

Individuals currently enrolled in the LIFE Program will not be enrolled in CHC unless they expressly select to transition from LIFE to a CHC managed care organization (MCO).

62

420,618CHC POPULATION

94%DUAL-ELIGIBLE

64%270,114Healthy Duals

18%77,610Duals in Nursing

Facilities

12%49,759Duals in Waivers

4%15,821

Non-duals in Waivers

2%7,314Non-duals in

Nursing Facilities

16%IN WAIVERS

20%IN NURSING FACILITIES

63

WHO IS NOT PART OF CHC?• People receiving long-term services & supports in the OBRA waiver & are not nursing facility clinically eligible

(NFCE)

• A person with an intellectual or developmental disability receiving services through the Department of Human Services’ Office of Developmental Programs

• A resident in a state-operated nursing facility, including the state veterans’ homes

64

WHAT ARE THE GOALS OF CHC?

65

CHC DESIGN COMPONENTS

66

Extensive Stakeholder Engagement

67

• Publication of Discussion Document and Concept Paper of the original program design for public comment

• Six statewide listening sessions

• Publication of the draft request for proposal for public comment

• Development of an advisory committee designed with a cross-section of participants to support program design and oversight

• Monthly webinars about program components

• Bi-weekly provider communications and in-person provider outreach sessions

• Participant outreach through mailings and in-person sessions

• Participant hotlines independent of CHC-MCOs

INTERDISCIPLINARY PROJECT MANAGEMENT

68

• Included Workgroups for:• Information systems requirements:

• Eligibility and enrollment

• Encounters

• Case management

• Quality data collection

• Procurement

• Quality Assurance and Program Evaluation

• Operations Readiness and Readiness Review

• CMS authority

• Rate setting

• Communications

CHC Configuration

69

• Three managed care organizations supporting all five CHC zones• Amerihealth Caritas

• UPMC Community HealthChoices

• Pennsylvania Health and Wellness (Centene)

Considerations

70

• Managed Care Final Rule

• Existing managed care configuration with Physical Health HealthChoices

• Behavioral health carve-out

• Population carve-outs

• Medicare Advantage enrollment penetration

• Staffing constraints

• Procurement process

• Continuity of care

Regional Phase In

Five Geographic ZonesPhase OneJanuary 1, 2018: Southwest Zone

Phase TwoJanuary 1, 2019: Southeast Zone

Phase ThreeJanuary 1, 2020: Lehigh/Capital ZoneNorthwest Zone; and Northeast Zone

Three managed care organizations supporting all five CHC zones:

• Amerihealth Caritas

• UPMC Community HealthChoices

• Pennsylvania Health and Wellness (Centene)

71

CHC LAUNCH UPDATE

72

2018 Community HealthChoices SW GOALS

73

• ASSURING NO PARTICIPANT SERVICE INTERRUPTIONS

• ASSURING NO INTERRUPTION IN PROVIDER PAYMENT

• SUCCESSFUL LAUNCH FIRST PHASE

CHC POPULATION DISTRIBUTION TO DATE

74

NFI Duals73%

HCBS Duals10%

HCBS Non Duals3%

LTC Duals13%

LTC Non-Duals1%

PA CHC Total Enrollments by Population

NFI Duals HCBS Duals HCBS Non Duals LTC Duals LTC Non-Duals

CHC SOUTHWEST JANUARY (Age Distribution)

75

Population Over 60 Under 60NFI Duals 51.2% 48.8%HCBS Duals 69.4% 30.6%HCBS Non Duals 33.3% 66.7%NF Duals 94.7% 5.3%NF Non-Duals 45.0% 55.0%Total Population 57.9% 42.1%

LESSONS LEARNED (SO FAR):

76

• Earlier stakeholder engagement opportunities with key population groups and group representatives

• Earlier in-person provider communication sessions• Enhanced communication materials regarding Medicare vs. CHC• More education and communication on participant rights and protections• Addition report development on enrollment and plan transfer scenarios• More communication on the LIFE (PACE) program as an enrollment alternative• Earlier address of data integrity issues• Earlier pre-transition• More provider information on IEB website• More provider training on Medicare vs. CHC

Industry Experience: Anthem/AmerigroupMerrill FriedmanLeigh Davison

MCO Approach to MLTSS ProgramsMerrill FriedmanLeigh Davison

May 2018

Anthem’s experience

79

In 2017, we supported the transition of nearly 1,000 members from custodial nursing facility living to community living.

Maximizing value of MLTSS programs

80

In our experience, MLTSS programs that include coverage for institutional as well as home and community based services (HCBS) with a holistic person-centered approach to health, well-being, and resiliency are most successful in achieving value that includes:

• Support for individual choice and self-direction• Successful community transitions and avoiding

unnecessary institutionalization • Increase access to quality HCBS

Systems Rebalancing

• Shift to person-centered, integrated care and services

• Expanded access to services• Improve health and well-being outcomes• Demonstrated success through data

Quality

• Savings gained through rebalancing and improved health and well-being outcomes

• Slow growth of program costs• Budget predictability

Sustainability

Four fundamentals of managed care

81

Access• Deliver the right

services at the right time in the right amount

• Help individuals and families find and access services and supports

• Support transitions to homes and communities

Quality• Put more attention

on preventive services and home and community-based services

• Identify needs and goals of individuals

Efficiency• Budget

predictability• Eliminate

duplication and fragmentation of services

• Address duplication and gaps in service

Coordination• Provide

coordination of care and services

• Increase collaboration between providers and managed care organizations (MCOs)

• Increase the number of individuals who select self-direction

82

Program structure• Integration is Key

• Fully integrate benefits, inclusive of mental health and substance use disorders, dental, LTSS, non-emergent transportation to allow for seamless care coordination and management• Simplifies the individual and provider’s experience, reduce

fragmentations, potential duplication and program costs

Implementation• Build Support

• Engage all stakeholders early and often• Cornerstone of successful programs is open communication

and collaboration• Member • Provider • Community

Post-implementation• Continued engagement and collaboration to build on the

program• Advisory Boards and committees

Transition from FFS to MLTSS• Program structure

• Implementation (pre & post)

Member

Provider

Community

Stakeholder engagement drives informed solutions

Transparent and ongoing stakeholder communication is critical throughout development, implementation and post go-live:• Proactive information sharing identifies best practices and lessons learned throughout in the

process• Opportunities for stakeholders to provide feedback so that plans can respond and take action

Members• Our member advisory

committees are tailored to the populations we serve and include people of all ages, people with disabilities and children/youth in foster care and families

Providers• Our approach to

supporting providers is built on collaboration, and we work to ensure providers are engaged in program design, processes and evaluation

State Partners• We meet frequently

with our state partners to promote transparency, ensure program goals are met, and share best practices across health plans

Our approach is always guided by the individuals and families we serve, as well as by the larger community of people, advocates, providers, and our state agency partners.

MLTSS best practices for HCBS support self-direction and inclusion

84

Community isn’t just about location – it’s about integration, inclusion, full participation, choice and opportunity. MLTSS programs must be structured to be flexible and innovative to ensure quality services are accessible and individualized to meet individual needs and preferences and allow for greater self-determination and achievement of personal goals.

Person-Centered MCOs Experienced in HCBS Service Coordination

Comprehensive Service Array

that Encourages Innovation

Caregiver Support and Connection

Provider Support and

Capacity Development

Meaningful Outcomes-

Based Quality Measures

Value Based Payments and

Incentives

Best practices for MCOs

85

Must be person-centered organizations, with leadership at all levels committed to:

• Building bench strength within service coordination and cross-functional support teams to facilitate person centered planning and practices

• Developing and implementing tools, policies and procedures to support person-centered practices• Delivering training and technical assistance to providers and other stakeholders

Care management systems must include:

• Interdisciplinary Service Coordination Teams with enhanced training and tools to coordinate Member needs across service systems

• Comprehensive assessments and integrated care plans that address all Member health and support needs, including HCBS Settings rule requirements, natural supports and Social Determinants of Health (SDOH)

• Population-specific clinical programs and innovative technologies to improve individual health and support independence and community engagement

• Systems to identify and track Member outcomes to support payment innovations

Anthem is committed to Person Centered Thinking© Trainer Certification as recognized by the Internal Learning Community for Person Centered Practices

Managed LTSS:Value of managing services and supports

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Responsibility

• Holds an entity responsible for a individual’s health care services and costs

• Serves as single point of contact for access, decreasing fragmentation, promoting integration and improving coordination

• Supports fulfilling the Olmstead mandate by incentivizing LTSS integrated in the community

Quality of Care

• Quality measurement and improvement

• Improves overall wellness and health outcomes

• Achieves member satisfaction

Efficiency

• Creates budget savings and predictability, while rebalancing LTSS funding

• Expands access to HCBS and can eliminate waiting lists

Person Centeredness

• Supports community inclusion, self-determination, independence, and deinstitutionalization

• Increases options for those receiving LTSS, their families and caregivers

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Specialized and expanded provider networks

Provider support

Building capacity

Value based contracting

Network adequacy

provides the foundation for access to care and services

Network access standards are an

important safeguard

Program policies can encourage

provider participation

Training and technical support

Capacity development

Value based incentives and

contracting

New approaches to HCBS QualityEvolving quality measurement approaches for HCBS:• The National Quality Forum issued Quality in

HCBS to Support Community Living in 2016 and continues to review and assess best practices for LTSS

• Consumer Assessment of Healthcare Providers and Systems (CAHPS) issued its HCBS Survey in 2017, with a supplemental employment module

• Several states utilize National Core Indicators LTSS and IDD measures

• Anthem has partnered with the MLTSS Association to monitor progress in the field of LTSS quality measurement and establish consistent measurements for reporting

Quality measures can be adapted to state priorities and should include non-medical domains such as:• Person-centered planning and

coordination• Choice and control• Community inclusion• Workforce

The NCQA LTSS Distinction was introduced in 2017, which applies a quality framework to assess an MCE’s ability to effectively coordinate LTSS.

Tennessee affiliate obtained distinction status November 2017 (Early Adopter)

Innovations for health and independence

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HCBS best practices include comprehensive service arrays that are flexible to encourage innovation in areas such as:

Self Directed Goods and Services innovations

Integrated, Competitive Employment Supports (including customized and self-employment options)

Peer Supports (including developmentally-adapted and caregiver peer options)

Caregiver Supports

Wearable Sensors and Remote Supports (for proactive health solutions and to reduce reliance on 24/7 staff)

Assistive Technology and Home Modifications

Non-medical Transportation Training and Supports

In Lieu of Services (options that are flexible to address emerging needs)

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•Ensure alignment of goals with state partners

•Listen and collaborate with individuals, families, providers, and stakeholders

•Commit to community engagement•Deliver on state and federal

requirements • Mega Rules, HCBS Settings Rule, and

State Contracts• Bring value to individuals (and their

families) accessing long term services and supports by enhancing quality of services through person-centered planning and coordination

Closing

Panel Discussion And Q & AModerator: Paul Saucier

92Panel Question

What question about MLTSSwould you like researchers toanswer? What actions mightyou be able to take if you hadthe answer?

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