States must do more to slow long-term care cost trends
Several initiatives designed to slow current cost trends in long-term care spending are highlighted in Medicaid Long-term Care: The Ticking Time Bomb, a report from the Washington, DC-based Deloitte Center for Health Solutions. These include "person-centered care," which provides the consumer with greater choice and alternatives, rebalancing to increase use of home and community-based services, and use of Medicare waivers for additional experimentation to improve care and manage cost.
Bob Campbell, vice chairman of Deloitte and head of the firm's state government practice, says that these are other potential avenues for states:
improved targeting of primary and secondary risk factors and co-morbidities;
increased home monitoring;
improved evidentiary health analysis to understand expenditures and which services are cost-effective;
ensuring continuity of case management and enhanced care management approaches.
"A number of states have implemented programs to help address the long-term care cost curve. There are promising examples addressed in the report," says Mr. Campbell. "However, given an aging population, the incidence of chronic disease, and health care reform's mandate for increased access to care, every state is going to need to do more on this front."
State Medicaid directors need better clinical data, incentive-based programs to reward case managers, and "increased sophistication in treating complex medical problems," says Mr. Campbell.
In many states, Medicaid agencies have delegated long-term care management to separate agencies responsible for their populations, but the Medicaid agency is still responsible and accountable to the Centers for Medicare & Medicaid Services due to funding. "Medicaid directors and these other agency heads need to improve collaboration to control costs and increase quality," says Mr. Campbell.
Mr. Campbell says that currently, Medicaid programs are focusing on health care reform implementation, including health information technology, health information exchanges, and developing improved eligibility enrollment processes.
"While this focus is proper, it is clear state Medicaid directors will need to enhance their focus on a longer-term approach to care management in long-term care in order to address this issue," says Mr. Campbell.
Some quality initiatives for long-term care, at the state level, are emphasizing consistent staffing and retention. Leslie Hendrickson, PhD, principal of Hendrickson Development, an East Windsor, NJ-based consulting group that helps to develop and strengthen long-term care programs, says that Colorado's pay-for-performance program, which includes staffing-related measures, is a model that other states would benefit by looking at.
Under Colorado's program, nursing homes get additional reimbursement if they can show they have career ladders, offer tuition reimbursement for staff, promote from within, and involve certified nursing assistants in care planning.
"There is a heavy emphasis on retention of staff and consistent staff assignments," says Dr. Hendrickson. "That goes directly to the heart of the turnover problem in direct care workers, by stabilizing that turnover through better salaries and working conditions."
High-cost, high-needs clients are already a growing focus for many Medicaid programs. Evidence shows that a small fraction of Medicaid beneficiaries accounts for the lion's share of expenditures.
Now that states will be assimilating an estimated 16 to 20 million additional Medicaid beneficiaries, finding ways to more cost-effectively provide care to this population is even more critical.
"It is fair to say that this is on the radar screen of most states," says Allison Hamblin, director of complex populations for the Hamilton, NJ-based Center for Health Care Strategies (CHCS). "Given the economic climate we have been in now for several years, and not seeing the light at the end of the tunnel in the short term, states are extremely focused on how to most effectively martial increasingly limited resources."
The expansion will be entirely federally funded at the outset, but the enhanced federal match is not permanent. At some point in the near future, states will have to come up with additional resources to cover the expansion population.
Some states have already implemented innovative approaches to identifying their impactable populations more effectively. The goal, says Ms. Hamblin, is "to put people who could really benefit from care management into some type of system of care, instead of being in a totally unmanaged fee-for-service environment, which is generally the case for these high-cost populations." Here are some approaches, outlined in the CHCS April 2010 policy brief Medicaid Best Buys: Critical Strategies to Focus on High-Need, High-Cost Beneficiaries:
Enhanced primary care case management (PCCM) programs
These programs, which provide more intensive care management for patients with complex needs, are in place in North Carolina, Oklahoma, Pennsylvania, Indiana, and Arkansas. "This is particularly effective when managed care is not a feasible or attractive option," says Ms. Hamblin.
Physical and behavioral health integration
Many beneficiaries in the highest-cost segment of the Medicaid population have physical and behavioral health conditions. Ms. Hamblin says that leading examples of integration include Pennsylvania and Washington.
"They are doing great work to make change at the system level to support and facilitate information exchange and alignment of incentives across physical and behavioral health providers, to promote an integrated system of care," says Ms. Hamblin.
Ms. Hamblin says that this integration is "a program imperative right now. If you want to more effectively manage costs and improve the care of complex, high-cost populations, it has to be done with an eye toward integrating behavioral health and physical health systems."
This can be done with either a carve-in or carve-out system, she says, so long as the channels of communication are open and support coordination.
Integrating care of dual eligibles
Currently, CHCS is working with seven states on the Transforming Care for Dual Eligibles initiative to design new programs to integrate care for individuals who are dually eligible for Medicaid and Medicare.
One option is the more traditional approach of integrating Medicaid and Medicare services through Medicare special needs plans, as New Mexico and Minnesota are doing. An alternative option is a shared savings model.
"Vermont and Massachusetts are interested in a model where the state would serve as the integrated entity, and get Medicare payments directly for dual-eligibles," says Ms. Hamblin.
What really works?
"In terms of what we know through robust evidence documented through randomized controlled trials, the unfortunate reality is that it takes a long time," says Ms. Hamblin.
Evaluations are currently under way for CHCS' Rethinking Care Program, which uses state-led pilots to test new care management approaches for Medicaid's highest-need, highest-cost beneficiaries. All of the projects in that program have external evaluations.
"This will contribute to the evidence base of what we know works to control costs and improve outcomes," says Ms. Hamblin. "However, it will be a while before we have that data."
Through its extensive work with states, CHCS has identified a set of critical components essential to improve care management for high-need, high-cost populations. "Through these efforts, we have come to feel pretty confident about some of these critical elements," says Ms. Hamblin. Here are several:
The ability to exchange information
Programs must make sure that those who are actually providing care have access to the full set of available information that could better inform the care that is being provided.
"Increasingly, there is a focus of hospital notification being provided real-time," says Ms. Hamblin. "That is one of the findings from some of the Medicare demonstrations that have informed our work to integrate care more effectively."
For instance, the physical health plan notifies the behavioral health plan in real time that one of their shared members has been hospitalized. Therefore, that member receives more timely outreach from both physical health and behavioral health providers, as appropriate.
Financial alignment
"When attempting to integrate across entirely separate systems of care, alignment of financial incentives can be a powerful tool to encourage collaboration," says Ms. Hamblin. Whether you are integrating Medicaid and Medicare benefits or physical health and behavioral health, the idea is to remove the disincentives for collaboration.
Pharmacy management
"Pharmacy data provide a near real-time and rich source of clinical information, particularly in the case of complex patients who receive care from multiple providers and systems," says Ms. Hamblin. The analysis and reporting of pharmacy data allows both prescribers and patients to be better informed of potential adverse drug interactions or to address adherence issues.
Consumer engagement is key
Partnering with health plans and other care management organizations to manage care has been occurring for some time in Medicaid programs. However, this is typically done only with children and their families. Adults with disabilities and those with multiple chronic conditions are typically not included, although these individuals constitute the bulk of the high-cost population.
"This segment has primarily remained in a fee-for-service system," says Ms. Hamblin. "It is easier for states to partner with health plans to serve children and their families. The provider networks are better understood. And for the most part, their health care needs are simpler."
Medicaid's highest-cost patients, on the other hand, have a diverse array of physical, behavioral, and psychosocial needs and require a far more sophisticated level of risk adjustment. "It can be challenging to set capitation rates for this population. That is one reason why moms and kids moved into managed care much earlier than the [Social Security Income] and [Aged/Blind/Disabled] populations," says Ms. Hamblin.
Psychosocial issues that go beyond traditional health care are as important for those populations, in many cases, as the underlying health issues. "We are still learning about what works," says Ms. Hamblin. "It is a multifaceted problem. The good news is, it's increasingly on the radar. We are learning more every day about more effective strategies to improve care for complex needs populations."
One trend is to try innovative ways to more effectively reach the patients who are identified for enhanced care management. "Some states are making incredible strides in that regard. Washington State, in particular, has developed some really novel strategies," says Ms. Hamblin.
One of the state's pilots achieved between a 50% and 70% enrollment rate in a care management program for a very complex population, which previously had an 18% enrollment rate. A few states are also piloting incentives to engage consumers more effectively. "A $20 grocery gift card goes a long way to someone being willing to have a conversation about having their needs met in a program like this," says Ms. Hamblin.
Motivational interviewing is a technique used by care managers that emphasizes the central role of consumer preferences in establishing care management goals. A treatment plan is built around their own stated needs and priorities. "We are observing that effective consumer engagement is critical to the success of these programs," says Ms. Hamblin.
New opportunities
Ms. Hamblin notes that there are "a variety of new opportunities through health reform to support these efforts."
States are now allowed to do a state plan amendment to create coordinated health homes for members with multiple chronic conditions. It specifies beneficiaries with serious mental illness in particular, and individuals with one chronic condition and a risk for developing another.
"There is enhanced federal match available for two years for states that pursue this option. Planning grants are available to support the development of these models," says Ms. Hamblin.
A related provision involves community health teams. There is the possibility of grants to support state efforts to develop community-based, coordinated patient-centered care approaches for people with multiple comorbidities.
"The challenge is for states to take advantage of these opportunities in the midst of expanding coverage to a whole new population," says Ms. Hamblin. "It is a balancing act, but there are some incredible opportunities."
Contact Ms. Hamblin at (609) 528-8400 or [email protected].
Several initiatives designed to slow current cost trends in long-term care spending are highlighted in Medicaid Long-term Care: The Ticking Time Bomb, a report from the Washington, DC-based Deloitte Center for Health Solutions.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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