Information Needs for Monitoring Managed Long Term Services and Supports Programs MESC Conference. Brian Burwell, Truven Health Analytics

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1 Information Needs for Monitoring Managed Long Term Services and Supports Programs 2013 MESC Conference Brian Burwell, Truven Health Analytics

2 States are Shifting LTSS into Managed Care Models How Should States Be Monitoring their MLTSS Programs? What Data are Needed for MLTSS Monitoring Activities? How Should Monitoring Activities Evolve Over Time? A Look to the Future 2

3 MLTSS is Not Your Traditional Medicaid Managed Care! Totally Different Populations Vulnerable Populations High Cost For many, health status will continue to decline Many are in the last years of life Different Use of Medicaid Benefits LTSS will dominate service use patterns Minimal use of other Medicaid benefits Most are dually eligible for Medicare and Medicaid Program Monitoring Objectives are Totally Different 3

4 Common Information Assets Available for MLTSS Program Monitoring Functional Assessment Data (Level of Care Data) Individualized Care Plan Data Enrollment Data MCO Reports Provider Network Data Encounter Data Service Visit Data (e.g. EVV System Data) Consumer Complaints (Grievances and Appeals, Ombudsman, etc.) 4

STATES WITH MANAGED CARE THAT INCLUDED LTSS AND ENROLLED DUAL ELIGIBLES GREW FROM 8 TO 16, 2004-2012 Source: CMS, 2012.

5 STATES WITH MANAGED CARE THAT INCLUDED LTSS AND ENROLLED DUAL ELIGIBLES GREW FROM 8 TO 16, Source: CMS, The Growth of MLTSS Programs: A 2012 Update. Downloads/MLTSSP_White_paper_combined.pdf 5

26 STATES ARE PROJECTED TO HAVE MANAGED CARE THAT INCLUDES LTSS AND ENROLLS DUAL ELIGGIBLES BY 2014 Source: CMS, 2012.

6 26 STATES ARE PROJECTED TO HAVE MANAGED CARE THAT INCLUDES LTSS AND ENROLLS DUAL ELIGGIBLES BY 2014 Source: CMS, The Growth of MLTSS Programs: A 2012 Update. Systems/Downloads/MLTSSP_White_paper_combined.pdf 6

7 Current and Upcoming Expansions of MLTSS Programs Florida currently expanding its mandatory MLTSS program statewide New York continuing to roll out its mandatory MLTSS program in phases New Jersey plans to carve in LTSS benefits into its mandatory managed care program in January 2014 Texas just announced selection of Texas+Plus contractors for rural areas Six States (RI, VA, TX, OH, ID, and NY) plan to implement dual demonstration programs in January

8 MLTSS Intake & Care Plan Implementation Process Care Plan Development Assessment & Eligibility Disease Management MCO #1 Provider 1 Care Plan Implementa:on Case Management Services Provider 2 Disease Management MCO #2 Provider 3 Provider 4 Provider Selec:on 8

9 Phases of MLTSS Program Monitoring Initial Shift into MLTSS Early Implementation Phase Network Development Phase Mature Program Phase 9

10 Initial Shift into MLTSS Priority is on Ensuring that LTSS Services to Consumers Are Not Disrupted as People Move from FFS to MLTSS Independent Care Plans for all consumers must be honored for a transitional period States should monitor transfer of Independent Care Plans from FFS environment to MLTSS contractors Existing LTSS providers should be paid regardless of whether they are formally in the MCO network or not State Must Monitor Whether Consumer Choice of MCOs is being implemented in accordance with waiver authority System documentation that consumers are informed of choice options 10

11 Early Implementation Phase Consumers Get Services, Providers Get Paid ---PK Kansas Required Daily Reporting from MCOs on new enrollments, provider network development, service authorizations, and claims paid Timely data on new program enrollments needed to monitor early implementation, including MCO assignments, and plan switching (Enrollment Broker) Aggressive monitoring of pending claims needed; LTSS provider report many problems with pended claims from MLTSS contractors Systems needed to monitor timely assessment and service plan implementation for new enrollees 11

12 Network Development Monitoring LTSS Networks are Rarely Finalized Prior to Program Implementation Many States are Employing Any Willing Provider Policies During Early Implementation Phase Information Needed on each MCO s Status in Network Development Detailed data needed on non-participating LTSS providers Some states using MLTSS models to expand capacity with certain provider types (e.g. assisted living providers) Many states using MLTSS to expand participant-directed service models for LTSS (need information system for monitoring) Some states using MLTSS models to expand covered LTSS benefits, requiring new provider types (e.g. pest control, PERS, home mods) 12

13 Monitoring of Mature MLTSS Programs States Should Look to CMS Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports for Ongoing Program Monitoring Requirements MLTSS Quality Strategy should be comprehensive and integrated with other LTSS initiatives such as Community First Choice, Balancing Incentive Program, and Money Follows the Person. Emphasis on sufficient and sustainable state infrastructure for quality monitoring of MLTSS programs Critical Incident Management reporting and investigation systems mandatory Emphasis on collection of high-quality encounter data reporting for quality monitoring purposes CMS encourages state to develop MCO report cards 13

14 Monitoring of Mature MLTSS Programs (Continued) Specific Quality Measures Left to the States Quality Measurement for MLTSS Monitoring Still in Early Phases of Development Keep up with what early implementers are doing (Arizona, Minnesota, Texas, Wisconsin) Examples of Quality Measures: Timeliness of Case Management Services Adherence to Individual Care Plans and Schedules Provider Retention of Personal Care Attendants Program Measures: Progress Towards LTSS Rebalancing 14

15 Monitoring of Mature Programs (Continued) CMS requires states to measure the consumer experience in MLTSS programs through consumer surveys CMS currently in the process of developing and field testing a CAHPS survey for HCBS services (state grants available) Focus groups are another potential method for monitoring the consumer experience Focus groups should be professionally conducted and videotaped Ensure that focus groups participants are representative of MLTSS population Highlights of focus groups can be prepared for senior policymakers Be sure to be HIPAA compliant!! 15

16 Conclusions LTSS Services Will Continue to Shift from FFS to MLTSS Models MLTSS Models Require Extensive Program Monitoring to Measure Program Performance Information and Data Systems Needed for MLTSS Program Monitoring are Much More Extensive than FFS or traditional managed care due to vulnerability of populations served States Have A Lot More Data to Draw Upon for Program Monitoring Purposes State Monitoring Systems Should be Used to Drive Policy Objectives Quality Measurement of Consumer Experience Still in Early Phases of Development 16

ABC's of Managed Care and What It Might Mean for Home & Community Based Services

ABC's of Managed Care and What It Might Mean for Home & Community Based Services This project is supported by a grant from the Pennsylvania Developmental Disabilities Council. David Gates DGates@phlp.org