Growth in MLTSS: Implications for Social Determinants of ...€¦ · Growth of Medicaid Managed...

Growth in MLTSS:

Implications for Social

Determinants of Health and

Community Based

Organizations

Joe Caldwell, Ph.D.

Director of Long-Term Services and Support Policy

National Council on Aging

Improving the lives of 10 million older adults by 2020 | © 2018 National Council on Aging 2

Background

NCOA leads the Disability & Aging Collaborative

▪ Informal coalition of more than 40 national aging and disability groups

working together to advance LTSS policy

▪ One of the first successful efforts to bring together aging and disability

organizations


Disability and Aging Collaborative and

• American Association on Health and Disability

• AARP

• ACLU

• ADAPT

• AFSCME

• Alliance for Retired Americans

• Altarum Institute

• ANCOR

• The Arc of the United States

• Association of University Centers on Disabilities

• Autism Speaks

• Autism Society of America

• Autistic Self Advocacy Network

• Bazelon Center for Mental Health Law

• Caring Across Generations

• Center for Medicare Advocacy

• Center for Public Representation

• Community Catalyst

• Dana & Christopher Reeve Foundation

• Disability Rights Education & Defense Fund

• Easter Seals

• Families USA

• Jewish Federations of North America

• Justice in Aging

• Leading Age

• Lutheran Services in America

• National Association of Area Agencies on Aging

• National Association of Councils on Developmental Disabilities

• National Academy of Elder Law Attorneys

• National Association for Home Care and Hospice

• National Committee to Preserve Social Security and Medicare

• National Council on Aging

• National Council on Independent Living

• National Consumer Voice for Quality Long-Term Care

• National Disability Rights Network

• National Health Law Program

• National PACE Association

• Paralyzed Veterans of America

• Paraprofessional Healthcare Institute

• SEIU

• United Spinal Association

• VNAA –Visiting Nurse Associations of America


Growth of Medicaid Managed LTSS

• Under Medicaid Managed Long-Term Services and Supports (MLTSS)

Programs, state Medicaid agencies provide capitated payments to managed

care organizations to provide long-term services and supports.o Most often in combination with acute and behavioral health services

o In some states integrated with Medicare for dually eligible individuals

• In 2007 (Lewis et al., 2018):

o 24 states operated MLTSS programs

o Enrollment in MLTSS programs more than doubled, from 800,000 in 2012 to 1.8 million in 2017

o States often operate multiple MLTSS programs (41 programs in the 24 states)

o Most common populations served are older adults (33 programs in 2017) and adults with physical

disabilities (30 programs in 2017).


States with MLTSS Programs Active or In Development

Source: NASUAD (2018) Medicaid Integration Tracker


Implications for Social Determinants of Health

• Reasons states have reported moving to MLTSS:

o Rebalancing LTSS from institutional to HCBS

o Reducing waiting lists for HCBS

o Improved care coordination

o Improved quality

o Budget predictability and containing costs

• Plans respond to what States put into the contracts

• Plans can provide added supplemental benefits and services

• Capitated payments provide plans with enhanced flexibility versus

traditional Medicaid


Implications for Community Based Organizations

• Be actively engaged early in the process as states consider MLTSS and

maintain ongoing engagement

o Opportunities to work with the State Medicaid agency to shape development of

programs, goals, and contract language

• 2016 Medicaid Managed Care Rule required:

o States and each managed care entity to establish stakeholder advisory groups for

design, implementation and oversight of LTSS

o State and managed care stakeholder groups must be engaged in the development of

the quality and performance improvement strategy, performance improvement plans,

and annual state managed care program assessment reports


Implications for Community Based Organizations

• Increasingly CBOs are contracting with MCOs

o Aging and Disability Business Institute:▪ https://www.aginganddisabilitybusinessinstitute.org/

o HCBS Business Acumen Center: ▪ http://www.hcbsbusinessacumen.org/

https://www.aginganddisabilitybusinessinstitute.org/

http://www.hcbsbusinessacumen.org/


Quality Measurement

• Quality measurement in MLTSS can drive desired outcomes:

o What gets measured gets done

o Can be tied to payment through incentives or penalties/withholds

o Can be tied to quality improvement projects

o Allow consumers to compare plans and make informed choices

• Significant gaps in HCBS related measures that have been developed

and endorsed by the National Quality Forum (NQF)

o NQF Workgroup on HCBS quality

o Significant work being done to develop HCBS measures▪ HCBS Experience of Care Survey (CAHPS) endorsed by NQF

▪ University of Minnesota RTC on HCBS Outcome Measures developing HCBS survey measures

▪ CMS contract with Mathematica developing measures for MLTSS, Duals, HCBS

□ Measure being considered related to falls risk, assessment, and plan of care


National Core indicators –Aging and Disability

• Partnership between NASUAD, HSRI, and participating stateso Currently 15 states participating

o Not all MLTSS specific, but some states are beginning to use NCI-AD as performance measures to compare plans

o Quality indicators in HCBS domains, including: service planning, rights, community inclusion, choice, health and care coordination, safety and relationships.

• Measures in NCI-AD related to falls and management of chronic conditions:o Do you (or somebody else) have concerns about you falling or being unstable?

o Has somebody talked to you or worked with you to reduce your risk of falling or being unstable? This could be a professional, family member, or a friend.

o Questions about unmet needs for home modifications (i.e. grab bars, bathroom)

o Do you have chronic conditions? Do you know how to managed that chronic condition?


Example from Texas 2015 NCI-AD Report

Source: NASUAD (2018) Medicaid Integration Tracker

12©2018 Aetna Medicaid

Proprietary and Confidential

MLTSS & CBO Partnerships

Alan Schafer, RN, Senior Director, LTSS May 23, 2018



| At Aetna Medicaid we believe in…

Improving every life we

touch

as good stewards to those we

serve.



Our members are at the center of everything we do

Aetna at a glance:

50,000 employees

23.5 million medical members

$61 billion revenue

160 years of national

and international experience

3rd largest managed care organization

in the U.S.


Proprietary and Confidential 15

Aetna Medicaid overview

30years of managed care

experience

Leader in managing medically complex populations at the local, community-

based level by integrating physical health, behavioral health, and social

economic status of members

3 millionmembers across 15

states

Over

23successful

implementations in the

last 2 years



©2018 Aetna Medicaid


Populations we serve



Physical, behavioral, and social integration

Fully integrated care encompassing physical

health, behavioral health and social and cultural

concerns of members

Strong provider partnerships and alliances

with community based organizations

Interdisciplinary care teams that include the

member and family

Leveraging technology to ensure care team has

a view of the whole person

Physical

health

Behavioral

health

Social and

cultural

issues

We have leading edge medical management

capabilities that focus on:



Respected

Community

Organization

Competence

with the

Population

Visionary

Leadership

| Choosing Partner Organizations



Nimble

Governance

Collaborative

Partner

Ability to

Comply with

Regulatory

Requirements

| Choosing Partner Organizations



Case management delegation

LTSS provider network contracting

Care Transitions

Initial health risk assessments

Locating hard to reach members

Waiver applications

Waiver service coordination

NF to community transitions

| Creating CBO Partnerships in our MLTSS States

Nationally recognized, locally focused

AZ

TX

FL

IL

OH

MI

NY

NJ

VA

CA



| Learning Lessons

Flexible model designs

Communication, problem solving

System access, security

Data sharing and reporting

Shared policies and procedures

Delegation oversight

Regulatory audits

CBO clinical expertise/staffing

Training

Value based reimbursement

We put the members we serve at the center of everything we do



We believe that fundamental change requires increased

collaboration

Thank You

Alan Schafer

Senior Director, LTSS

[email protected]

22

Our Long and Winding Road to CDSME Reimbursement under MLTSS

May 23, 2018 NCOA Center for Healthy Aging Annual Meeting

VIRGINIA DEPARTMENT FOR AGING AND REHABILITATIVE SERVICES (DARS)

TIMELINE: CDSME IN VIRGINIA

• 2005: Introduced by Virginia Department of Health

• March 2010: VA receives a 2-year grant from Administration on Aging

• September 2012: VA receives a 3-year grant from Administration for Community Living (ACL)

• August 2016: VA receives a 2-year grant from ACL

DARS is the lead state agency. Area Agencies on Aging lead at the local level.

24

Provides and advocates for resources and services to improve the employment, quality of life, security, and independence of older Virginians, Virginians with disabilities, and their families.

25

• Statewide Medicaid managed long term services and support programs serving approximately 210,000 individuals with complex care needs.

• Integrated delivery model across the full continuum of care.

• Care management at the heart of the CCC Plus.

• Focuses on improving quality, access and efficiency.

COMMONWEALTH COORDINATED CARE PLUS(CCC PLUS)

DMAS/DARSCOLLABORATION

• Early grant activities: Post card mailing to older Medicaid beneficiaries, helped organize and host statewide meeting

• Invited DARS to meetings with MCO’s: Opportunities to orient MCOs to CDSME

• Supported DARS/MCO discussions in 2015 to explore ER utilization study

• In the CCC Plus RFP: Strongly encouraged MCOs to partner with DARS to offer CDSME services as an enhanced member benefit to beneficiaries under the MLTSS program.

TIMELINE: VIRGINIA PREMIER HEALTH PLAN (VPHP)/DARS COLLABORATION

6/16: Invitation from VPHP, subsequent meeting and presentation. VPHP sends letter of intent to DARS the same day

8/16: DARS begins Scope of Work draft

10/16: Conference call with Virginia Premier to discuss Scope of Work. Referrals to be made through No Wrong Door electronic tools

12/16-1/17: Planning discussions with Virginia Premier

Months of back and forth on contract wording

VIRGINIA PREMIER HEALTH PLAN (VPHP/DARS COLLABORATION

4/17: Fully executed contract with VPHP.BAA has also been finalized and executed

BUT, several issues to be resolved:• Signed consent • Routing referrals to AAA subcontractor• Agreement on handling referrals to CDSME

“satellite” AAAs

Winter/Spring 2018: Training and refresher training for VPHP and AAAs

Finally, on May 1, 2018 the referral system goes live!

VPHP/DARS CONTRACT BASICS

• Coordination by DARS of referral and billing processes

• Programs delivered by Area Agencies on Aging

• Electronic referrals from Virginia Premier using Virginia’s No Wrong Door technology

• Virginia Premier reimburses DARS based on member workshop attendance

• DARS contracts with AAAs and reimburses based on member attendance

QUESTIONS?

April HolmesCoordinator of Prevention Programs

[email protected]

30

mailto:[email protected]

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