MLTSS: Key to Caring for Duals
We all want to do it: Provide the best healthcare services for our members. For our vulnerable population, this can be complicated, if not near impossible to achieve, given the current healthcare issues at hand.
About 9.6 million people in the United States are covered by both Medicare and Medicaid, including low-income seniors and younger people with disabilities, according to the Kaiser Family Foundation (kff.org). Kindred Healthcare’s “Making Sense of Healthcare Reform: Dual Eligible” points out, as baby-boomers reach their 65th birthdays, an estimated 10,000 individuals become eligible for Medicare-covered services each day. Couple this fact with the expansion of Medicaid eligibility in many states, the result is a much larger dual-eligible population in the near future. These dual-eligible beneficiaries are almost, by definition, a high-needs population often demonstrating to be the poorest and sickest beneficiaries of both programs. Consequently, they account for a disproportionate share of spending in both programs and, according to the Medicare Payment Advisory Commission (MedPAC), dual-eligible beneficiaries cost Medicare about 60 percent more than non-dual eligibles.
Medicare and Medicaid were never operationally designed to work as a single health plan (and it shows). Kindred Healthcare explains further in their article there are coverage and payment policies offered by 50 separate and unique Medicaid policies. Simplified, Medicaid pays for almost all long-term care (LTC) services, while Medicare covers more acute care such as emergency department visits. Dual eligibles are constantly bouncing back and forth between the two government-funded programs; Medicare pays for an operation and Medicaid for long-term recovery.
It’s complex, inflexible, and silo-infested.
Health plans need to identify ways to better manage escalating costs and make payment reform a fundamental requirement in both improving quality and containing costs. The answer is multi-faceted.
Move from Volume to Value: According to an article in governing.gov, the volume-driven Fee-for-Service (FFS) payment system for the Managed Long Term Services and Supports (MLTSS) of the aging and disabled LTC populations is focused on volume. The volume-driven FFS payment system can be replaced with pay-for-performance and care management initiatives including performance-based contracting, shared risk, and capitated payments to providers and managed care organizations (MCOs). Success of these initiatives is dependent on the plan’s ability to track and analyze the outcomes. Focusing on outcomes can transition staff perspective, actions, and care plan goals to be more person-centered.
Improve Access to Home- and Community- Based Care: Tennessee implemented a pilot based on a decade-long study published in Health Affairs in 2009 which found states with established home- and community-based programs were able to reduce their overall Medicaid LTC spending by nearly 8 percent. Acting on the results of this study, Tennessee lawmakers introduced a new program called CHOICES in 2010, which was a way to help seniors on Medicaid receive home- and community-based care instead of living in nursing homes. Programs like CHOICES are estimated by the Bowles-Simpson presidential commission of fiscal reform to possibly produce savings up to $12 billion by 2020. Nursing homes, as a default option for aging and disabled beneficiaries, will quickly prove unaffordable in the long run not to mention negatively impact satisfaction ratings. After all, AARP conducted a study of individuals over the age of 50 and found more than 80 percent prefer aging in their own home than in an institution.
Provide Feedback to CMS: September 14, 2015, is the deadline to provide the Centers for Medicare & Medicaid Services (CMS) comments regarding their newly released rule, Reform of Requirements for Long-Term Care (LTC) Facilities. This proposed rule would revise the requirements LTC facilities must meet to participate in the Medicare and Medicaid programs. An emphasis has been made on theory and practice of service delivery and safety in order to achieve broad-based improvements both in the quality of healthcare furnished through federal programs, and in patient safety, while at the same time reducing procedural responsibilities on providers. New sections address facility responsibilities for protecting resident rights and enhancing quality of life; requirements for comprehensive person-centered care planning; changes relating to behavioral health service and laboratory, radiology, and other diagnostic services; requirements for Quality Assurance and Performance Improvement (QAPI) and Compliance and Ethics Programs; and staff training requirements. CMS estimates costs to comply per facility over a span of two years will be about $40,685.
Care Coordinate Effectively: In John Gorman’s blog, “You’re Doing it Wrong in Care Management” issued May 18, 2015, he explained how modernizing your approach in care management into data-driven care coordination “pods” can help you better manage your high utilizers and those about to become them. By “doing it right in case management,” you can both contain costs and improve quality.
Resources
GHG can help your transform a total change in the delivery, payment, and care coordination efforts necessary to provide positive outcomes for a very challenging patient population. We can help you learn what works best in coordinating quality-driven care for dual-eligible beneficiaries — and what approaches would be unsustainable. Contact us to get started today>>
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