Managed long term services and supports (MLTSS)

Transcription

1 Managed long term services and supports (MLTSS) Innovations in health care delivery for the Medicaid and dual eligible population An EXL whitepaper Written by Linda Friedman, RN BSN MA Elizabeth A. Haley, RN BSN CCM

2 Managed long term services and supports (MLTSS) refers to an arrangement between state Medicaid programs and managed care plans through which the managed care organizations receive capitated payments for the segment of their member population that qualifies. In fully integrated models, these payments for MLTSS, which can include in-home and community based services (HCBS) and/or institutional-based services, are combined with those for primary, acute, and behavioral health services, and the capitation payment is more comprehensive. The use of MLTSS has been associated with cost savings and more patientcentered care for Medicaid beneficiaries. By providing long-term supports and services in an integrated, coordinated fashion, MLTSS programs can lower the costs of services, support integrated care delivery, prevent extended inpatient hospital stays and readmissions, limit dependency on nursing homes and other extended care facilities, and extend an individual s living independence as long as feasible. MLTSS programs have grown significantly over the past decade and are expected to increase even more in the coming years. Between 2004 and 2012, the number of states with MLTSS programs doubled to 16 from eight and the number of people receiving long term services and supports (LTSS) through managed care programs increased to 389,000 from 105,000. By 2014 the number of states implementing MLTSS programs reached 26, with continued growth expected. In 2015, the Centers for Medicare and Medicaid Services (CMS) announced it anticipates further growth of such programs following the implementation ExlService Holdings, Inc.

3 of Medicare-Medicaid financial alignment models. As a result, CMS and the states are expecting significant reductions in costs associated with health care payments for this population while participating managed care organizations are challenged to provide a broader continuum of care with a fixed amount of dollars (capitation model). Medicare - Medicaid financial alignment initiative Integration of care for Medicare- Medicaid enrollees A longstanding barrier to coordinating care for Medicare-Medicaid enrollees has been the financial misalignment between Medicare and Medicaid. To begin to address this issue, CMS is partnering with states to test models that better align the financing of these two programs. Beginning in 2012, states approved for demonstration projects were required to provide evidence that their program could fully integrate care across the full range of primary, acute, behavioral health and long term supports and services. About the Medicare- Medicaid coordination office Advancing care for people with Medicaid and Medicare Established by Section 2602 of the Affordable Care Act (ACA), the Federal Coordinated Health Care Office (Medicare- Medicaid Coordination Office) serves those enrolled in both Medicare and Medicaid (Medicare-Medicaid beneficiaries, also known as dual eligibles). This agency, working across federal agencies, states, and other stakeholders, is charged with ensuring that the dual-eligible population has full access to seamless, high quality health care and that the system is as costeffective as possible, while partnering with states to design and develop innovative care models ExlService Holdings, Inc.

4 The impact of MLTSS on health plans Historically, the population most likely to participate in these programs has been difficult for health plans to manage. These members are typically resistant to engaging on an ongoing basis while their needs are complex, often requiring a multidisciplinary team of care managers and service providers. So the growth of MLTSS plans will challenge health plans in several ways and require: Designing non-traditional care models that require different skill sets for staff than traditional case management Employing the use of portable technology to monitor member s health status in home and/or community-based settings Improving data collection and more sophisticated data aggregation Leveraging analytics to measure utilization for financial trending and outcomes for quality reporting. Compliance requirements across multiple state and federal agencies will also strain health plan operations in many different arenas. To maximize the positive experience of beneficiaries as they make the transition to more integrated service models, CMS developed 10 key principles inherent in a strong MLTSS program. CMS uses these guiding principles in its review, approval, and oversight of states MLTSS programs. Adequate planning and transition strategies Stakeholder engagement to include beneficiaries, providers, and advocacy groups of impacted populations Enhanced provision of home and community-based services, allowing care to be delivered in the most integrated setting Payment to managed care plans should support the goals of the MLTSS programs, including: + + Improving the health of populations + + Improving the beneficiary experience of care + + Reducing costs ExlService Holdings, Inc.

5 Ongoing support and education for all beneficiaries, particularly those most vulnerable Ensuring that beneficiaries medical and non-medical needs are met Comprehensive and integrated service package, including behavioral health, physical health, community-based and institutional long term support services MLTSS plans are required to have an adequate network of qualified providers Assurance that states will address beneficiary vulnerability and assist vulnerable populations in obtaining appropriate services Assurance that quality standards will be met and maintained Since most LTSS users are dual eligible, states have taken varied approaches to coordinate across the two programs. MLTSS programs can be very diverse and can include: Programs in which capitated payments are made by the state to contractors (such as managed care organizations) primarily for LTSS Programs that make capitated payments to contractors for all or most Medicaid covered services Fully integrated Medicare-Medicaid programs that include all Medicaid and Medicare covered services Many states have fully integrated programs, in which contractors are at risk for both Medicaid and Medicare services, and members must choose the same managed care entity for both sets of benefits. CMS standards and conditions In addition to the 10 guiding principles outlined previously, CMS will enforce standards and conditions for all MLTSS programs that include, but are not limited to, the following: ExlService Holdings, Inc.

6 1. Integration of Benefits coordination of all necessary Medicare and Medicaid covered services 2. Care Model must offer personcentered coordination of care, including robust and meaningful mechanisms for improving care transitions (e.g. between providers and/or settings) to maximize continuity of care 3. Beneficiary Protections such as enrollment and disenrollment procedures, grievances and appeals, continuity of care, etc. 4. Network Adequacy adequate access to medical and supportive service providers 5. Measurement/Reporting systems in place for oversight and monitoring to ExlService Holdings, Inc. ensure continuous quality improvement, including ability to collect and track data on key metrics 6. Enrollment each state will identify enrollment targets 7. Expected Savings must demonstrate that the model being tested will achieve meaningful savings while maintaining or improving quality 8. MCOs must demonstrate ability to provide medical and prescription drug benefits to eligible beneficiaries 9. Provider network must be adequate to provide enrollees with timely and reliable access meeting standards of Medicare Part C and Part D 10. Formulary of covered medications must meet Medicare Part D and Medicaid requirements Many managed care companies expanding into the MLTSS market have a limited understanding of long-term supports and services (LTSS) and of the LTSS provider community. Managed care companies are used to contracting for acute, highly regulated and licensed health care services but might not be experienced in contracting for more socially oriented, less defined and personalized LTSS services. Further, managed care organizations (MCO) are unaccustomed to contracting with unlicensed agencies with limited corporate infrastructures.

7 MCOs are used to paying claims for episodic acute care services, such as births, hospitalizations, specialty visits, etc., as opposed to services used daily, and in some cases, continuously, by LTSS recipients. States expect MCOs to develop new, more cost effective and patient-centric service models for LTSS populations than those traditionally used in the fee-for-service (FFS) system. Developing these new models requires more creativity and innovation than many MCOs are used to. It is clear however that states are turning to MLTSS models with the hope that private sector organizations can be more innovative in meeting the complex needs of LTSS populations than is feasible within the constraints of the public sector. MCOs planning to participate in MLTSS programs need to understand a broad range of impacts, which fall into three main categories: 1. Operational + + MCOs will need to plan more creatively to develop new innovative service models for LTSS populations (e.g. use of more home and community-based services) + + Provider Relations departments will need one or more LTSS specialists who serve as the single point of contact for LTSS providers to answer questions and/or triage issues + + MCO clinicians, particularly in case management, will need to be more collaborative and engaged in new and different ways when coordinating care for the MLTSS population + + Health plan leadership will need to design and implement financial models that reward care coordination and quality outcomes (e.g. value-based reimbursement) in place of traditional FFS 2. Technology + + MCOs will need to employ the use of newer technologies that will allow remote monitoring of member s health status ExlService Holdings, Inc.

8 + + Field Case Managers will need to be more portable in order to meet program requirements for assessing needs and Case study EXL Healthcare Meeting the needs of MLTSS recipients managing care for recipients in the community 3. Data + + Customizable care management systems that facilitate care coordination while able to comply with the everchanging federal and state regulatory requirements + + Advanced data collection, aggregation, and analytics sufficient to meet ongoing monitoring and reporting needs Following a successful transition from an existing care management software platform to EXL Healthcare s CareRadius suite in fall 2013, a large NJ-based managed care organization tapped EXL s clinical and technical consultants to build best practices that allowed the company to utilize the new software in ways that facilitated compliance with MLTSS program regulatory requirements. One outcome led to enabling fieldbased Case Managers to utilize mobile technology, including tablets and Wi-Fi hot spots, to complete in-home assessments for participants who were potentially eligible for the MLTSS program. Whenever a field case manager is unable to connect to the medical management software remotely, surveys were designed to allow nurses to collect data. Features of the survey include: Data Validation fields maintain the same control types as the configured CareRadius survey Upload Features enable the survey to be uploaded and stored to the CareRadius database when connection to the health plan network is available Portable Document Format (PDF) Enabled allows for capture of member signature and for printing of documents to leave with recipient ExlService Holdings, Inc.

9 In summary The MLTSS program member population poses unique care management challenges that require a greater rigor of standard care management processes, augmented by technology and data analytics. Harnessing structured and unstructured data, along with innovative mobile technology, field case managers have the tools necessary to perform comprehensive assessments and creation of cost-neutral care plans at the first encounter with a member. Health plan leadership will need to prioritize advanced, member-centric care management platforms that will integrate with existing systems (e.g. claims) to facilitate compliance with state and federal regulations while providing convenient access to multiple sources of member data that will allow case managers, utilization management (UM) staff, and providers to effectively and efficiently coordinate care for program participants. References Medicare-Medicaid Coordination (CMS.gov) Medicaid Managed Long Term Services and Supports (Medicaid.gov) managed-long-term-services-and-supports Transitioning Long Term Services and Support Providers into Managed Care Programs - Brian Burwell, Jessica Kasten, May 2013 Prepared by Truven Health Analytics for the Centers for Medicare and Medicaid Services (CMS), Disabled and Elderly Health Programs Group as a subcontractor to The Lewin Group downloads/transitioning-ltss.pdf EXL, a premier provider of medical management software, clinical operations support, and predictive analytics for the healthcare industry, closely monitors the advances underway to provide a comprehensive benefit package in the most integrated setting to the dual-eligible population across the country. EXL Healthcare continues to develop and improve its products (e.g. enhanced reporting capabilities) and services (e.g. business process consulting) to meet the comprehensive needs of this unique member population ExlService Holdings, Inc.

10 EXL (NASDAQ: EXLS) is a leading business process solutions company that looks deeper to drive business impact through integrated services and industry knowledge. EXL provides operations management, analytics and technology platforms to organizations in insurance, healthcare, banking and financial services, utilities, travel, and transportation and logistics, among others. We work as a strategic partner to help our clients streamline business operations, improve corporate finance, manage compliance, create new channels for growth and better adapt to change. Headquartered in New York and in business since 1999, EXL has approximately 23,000 professionals in locations throughout the U.S., Europe and Asia. EXLservice.com 2015 ExlService Holdings, Inc. All Rights Reserved. For more information, see GLOBAL HEADQUARTERS 280 Park Avenue, 38th Floor, New York, NY T: F: UK SALES OFFICE 6 York Street, London, W1U 6PJ, United Kingdom T: F: INVESTOR RELATIONS Steven Barlow Vice President Investor Relations Phone: ir@exlservice.com United States United Kingdom Czech Republic Romania Bulgaria India Philippines Colombia