Using State Flexibility to Improve Medicaid Long Term Services and Supports

February 26, 2018


More than 12 million Americans receive long term services and supports, and as the population continues to age, this number is only projected to grow.
Medicaid is the single largest payer of LTSS. Efforts to deliver Medicaid LTSS through managed care arrangements and, whenever possible, in the home and community are becoming increasingly common throughout the country. Federal law grants states considerable flexibility in how they design their programs to implement these reforms. The briefing highlighted the emerging best practices in Medicaid LTSS program design that promote high-quality, cost-effective, person-centered care.


  • Cindy Mann, JD, Partner, Manatt, Phelps & Phillips, LLP
  • Michelle Herman Soper, MHS, Director, Integrated Care, Center for Health Care Strategies
  • Tom Betlach, MPA, Director, Arizona Health Care Cost Containment System
  • Bror Hultgren, MBA, MSHA, United Healthcare Community & State at UnitedHealth Group, Inc.

The Alliance would like to thank The SCAN Foundation and the Milbank Memorial Fund for making this event possible.

The SCAN Foundation is advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence.

The Milbank Memorial Fund works to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience.


12:00 – 12:10 p.m. Welcome and Introductions
 Sarah Dash, MPH @AllHealthPolicy
Alliance for Health Policy
 Bruce Chernof, MD, FACP @DrBruce_TSF
The SCAN Foundation
12:10 – 12:45 p.m. Presentations
 Cindy Mann, JD @ManattHealth
Manatt, Phelps & Phillips, LLP
 Michelle Herman Soper, MHS @CHCS_Medicaid
Center for Health Care Strategies, Inc.
 Tom Betlach, MPA @TomBetlach
Arizona Health Care Cost Containment System
 Bror Hultgren, MBA, MSHA
United Healthcare Community & State at UnitedHealth Group, Inc.
12:45 – 1:20 p.m. Question and Answer Session
1:20 – 1:30 p.m. Closing Remarks
 Christopher Koller, MPPM, MAR @CKollerMilbank
Milbank Memorial Fund

Presentation: C. Mann and M. Herman Soper

Presentation: T. Betlach

Presentation: B. Hultgren

Event Resources

Additional Materials


[Please note that this is an unedited transcript, please refer to the video of the event for direct quotes]

SARAH DASH:  We will go ahead and get started. I’m Sarah Dash, and I’m President and CEO of the Alliance for Health Policy, and we’re delighted to have you here today, joining us for today’s briefing on using state flexibility to improve Medicaid long-term services and supports. For those of you not familiar with the Alliance, we are a non-partisan organization dedicated to advancing knowledge and understanding of health policy issues. And today’s briefing, we will be live tweeting, using the hashtag #AllHealthLive, so feel free to use that and to submit question by Twitter as well.


Before we get started, I would like to thank the SCAN Foundation, and the Milbank Memorial Fund for making today’s briefing possible. The Alliance is really grateful for their support. And I’m going to introduce our panel of experts in a moment, but before I do that, I would like to introduce Dr. Bruce Chernof, who is President and CEO of the SCAN Foundation, to make some opening remarks. In 2013, Dr. Chernof served as Chair of the Federal Commission Long Term Care, which produced a bi-partisan report to Congress, recommending reforms for the nation’s long term care financing delivery system and workforce needs, and he will tell you more about the SCAN Foundation’s involvement in the aging and long term care space. He completed his residency and chief residency in internal medicine, as well as a fellowship in medical education at UCLA. So, we’re thrilled. Thank you, Dr. Chernof.


  1. BRUCE CHERNOF: Good afternoon, everybody, it’s really a pleasure to be here today on behalf of Chris Kohler, President and CEO of the Milbank Memorial Fund, and myself. I want to thank all of you for being here today. We’ve got a wonderful panel of speakers. We appreciate the outstanding work of CHCS and Manatt Health, in putting together today’s toolbox that we’re going to talk about. And the wonderful Alliance for Health Reform staff. Alliance for Health Policy staff, who are here. Thank you. I’m old, it shows. For putting together today’s briefing and doing really a wonderful job in many settings, bringing emphasis and attention to important issues.


Again, for both Chris and myself, I think we see this as an exciting day. There is an opportunity with the passage of the Chronic Care Act, and work that’s gone before, to help states really take the next step in their Medicaid programs to build on strengths, to pick up on new opportunities, to integrate services in ways that are far more effective. To help get people who are in nursing homes back to home, where it makes sense. To braid together financing that has traditionally been kind of siloed, and we see this as a real down payment on advancing those discussions.


So with that, I want to get out of the way the presenters, and I will look forward to Chris giving us some summary thoughts at the end. So, thank you.


SARAH DASH:   Great. Thank you, Bruce. Can everyone hear me? Well, great, I’m going to go ahead and introduce our panelists and then they will give some presentations and we will have time for Q&A and discussion.


Our first presenter today will be Cindy Mann, who is a partner at Manatt Phelps and Phillips. Cindy formally served as Deputy Administrator at the Centers for Medicare and Medicaid Services, and Director of the Center for Medicaid and Children’s Health Insurance Program Services at CMS. She has her JD from New York University School of Law. And there are more complete bios in your packet, so I’m not going to do justice to everybody today.


Next, we will hear from Michelle Herman Soper, who is Director of Integrated Care at the Center for Healthcare Strategies. Prior to joining CHCS, she served as a Special Assistant to the Executive Director and the Acting Communications Director for the Medicaid and CHIP Payment and Access Commission, or MACPAC, which many of you are hopefully familiar with. Michelle has her master’s degree in Health Science from the Johns Hopkins School of Hygiene and Public Health.


Following Michelle’s presentation, we’ll hear from Tom Betlach. Tom is Director of Arizona’s Medicaid agency, a role he’s held since 2009. Prior to becoming Medicaid Director, Tom served as Deputy Director of the agency for nearly eight years, and as State Budget Director for five years, prior to that. Tom holds his master’s in Public Administration from the University of Arizona.


Finally, last but not least, we’ll hear from Bror Hutgren, who is Senior Vice President of Direct Care Delivery, and Specialized Care Models at United Healthcare Community and State, which serves nearly 6.4 million Medicaid beneficiaries in 27 states. In his role, Bror also serves as Chief Executive Officer of Team MD, a physician practice focusing on delivering intensive in-home primary care with integrated care management, for those with significant functional challenges or chronic illness. Bror received his MBA and Master of Science and Health Administration from University of Colorado at Denver.


Then finally, following the presentations, in a Q&A period, I will invite Chris Koller, President of Milbank Memorial Fund, to make some brief closing remarks. So thank you all very much for being here and sharing your expertise. And with that, I’m going to turn it over to Cindy to help get us started. Just make sure your mic is on.


CINDY MANN:  Thank you. It is great to be here, and it’s great to see so many people that I know and have worked with over the years, as well as new faces. And I want to start off first by thanking the SCAN Foundation, and the Milbank Memorial Fund for their support of the toolkit that Manatt and CHCS worked on. I absolutely want to also thank the Alliance for pulling us all together over lunch, to have interesting discussion about an area that I think gets far less attention than it deserves, which is long-term services and supports.


So I’m just going to make a few opening remarks, in terms of background, and then get into two of the strategies that we’ve highlighted in our report, and that we’re going to talk about here, although obviously not in as much detail as the report. The two strategies are broad, and there is a number of different approaches within those strategies. They are broadly to think about how Medicaid can be rebalanced in terms of the delivery of its long-term services and supports, and make sure that people are served in the most appropriate setting, which can be in a nursing home setting, and which also can be in a home and community-based setting. So we will talk about some of those initiatives.


And then we’re also going to be talking about the ways in which states have and can continue to advance the integration of long-term services and supports with other healthcare services or with healthcare services that people need, historically, and in many cases still today. The delivery system, the oversight, the management, the financing, is of long-term services and supports, can be very separate and siloed from the delivery of physical healthcare, mental healthcare, behavioral healthcare. And of course, one can imagine that that’s not the ticket to success in terms of really delivering better care for people, and doing so in a way that’s cost effective.


Let me start with the growing demand and role for Medicaid in long-term services and supports. A little bit of why are we here today. Why is this such an important topic? And the two parts of this graph, I think, tell at least an important part of that story, although not all of the story. One is that the population of course, no surprise to anybody, is aging. And the baby-boom generation is in fact hitting it’s over 65 zone that we were all projecting for many years. It has happened, and that baby-boom will continue. The tail end of it is actually between 2020 and 2030. But we are seeing, therefore, a greater share of the population being over 65, but we’re also seeing people live longer, so a greater share of the elderly population is in fact increasingly over 85. People are living longer, that’s a good thing, but they are also living with complex health and social and economic needs, and needs to just help them with daily living. So the population and the demand is growing, and Medicaid — we’re talking about Medicaid because it is the single largest source of payment for long-term services and supports. And you see on the graph there, that about 43% of all spending is for long-term services and support, is paid for by the Medicaid program. And certainly significantly more than the Medicare program, and that accounts for about 30% — about three out of every ten dollars that the Medicaid program spends. And if you think about the discussions that we’ve had over the last year or so, about restructuring Medicaid, it often is not well recognized that, A: Caring for people with disabilities, and people that are elderly, is a significant function, and the largest expenditure for the Medicaid program. Secondly, the delivery of long-term services and supports, and the payment for those supports is uniquely been a Medicaid role. Not necessarily completely by design, a little bit by default and over the years.


While these two graphs are really important, I just want to make a couple of points:  One is that while the focus in this graph is on the aging population, the people who need long-term services and supports is a very heterogeneous group of people. Many are younger individuals, people with disabilities, babies who need care from birth, as well as our elderly population. So that makes the challenge of doing long-term services and support right, and integrating it with the broader health — physical health and mental health systems — even more challenging, but it’s a really important concept to recognize.


So let me talk about some recent trends, and I identified them as areas that we are going to focus on today, which is looking at the rebalancing of Medicaid out of institutional care, not completely out of institutional care, but obviously balancing so that more of the services are in the homes and in the communities. There has been a lot of new authorities that have helped, and new funding sources that have helped spur that on, but there is also a real demand by families, and by communities, to live in the community, and to be served at home when at all possible. Then we are going to talk about, as I mentioned, the integration — bringing long-term services and support into the care of a whole person in a way that is very much a person-centered approach.


We developed together — CHCS and Manatt Health, developed this toolkit, because as Bruce Chernof said, this is a really important and exciting time for states to be moving ahead and there’s actually quite a bit of activity going on. There’s quite a bit of flexibility in the Medicaid programs specifically, and then through the opportunities to do waivers under different authorities under federal law. And yet, it’s challenging. And so the point of the toolkit was to begin to surface some of the exciting things that are going on in some states, and really to help some of the other states that are just getting into his area, to be able to learn from their colleagues. And we are going to hear later from one of our states, Arizona, from Tom Betlach, whose really been working on this for quite a while.


I’m going to touch upon re-balancing. I always shutter at the notion of re-balancing, because that suggests that we’ll get to a point that we used to be at, that is a better place to be, and we never were balanced in terms of the provision of long-term services and supports. And that’s a feature of lots of historical things that we can talk about sometime on Q&A or over coffee or a bottle of wine, but the bottom line is that it’s been more complicated for states to provide those services in home and community-based settings for a number of different reasons, including the authorities under federal law. But increasingly, states are moving in that direction for a couple of different reasons. One, it’s what people prefer. Secondly, it’s usually much less expensive than institutional care, although home and community-based services can be, for somebody with high needs, a costly service relative to other care that people are getting. And also there is the Americans with Disabilities Act, which requires, under the decisions by the Supreme Court, under the Umstead Decision, that people be served. It’s not a Medicaid, it’s an ADA requirement, that people be served in the least restrictive setting possible. So all of those features over the years have really pushed states forward, pushed families forward, and pushed philanthropy forward to begin to really think about how to better serve people into the community.


I’m just going to highlight a couple of different strategies that states have been embarking on. We’re not going to cover all of them, but we can pick a few up, as we go along. One key area is to develop — and I know this may sound dry, but it’s really critical, is the infrastructure to make sure that when somebody has a need for long-term services and supports, and hopefully well before they evidence the need for long-term services and supports, there is a person-centered plan to move forward, and there is a place, and a way to get the information about all of the options that people have. I literally spent some portion of my weekend, which I think all of us do in our capacities as family members, as community members, helping somebody who suddenly — you know, is 85, had two falls, had surgery, and didn’t have a plan of what to do, and couldn’t go back to his home with stairs. And didn’t know what to do. And the institutions that he was getting care from is hospital and the post-acute care facility. It’s much easier to figure out at that point, I’m going to find a nursing home for you. Right? Then to stitch together a home and community-based plan that probably means another setting for him, because he can’t go back to his stairs, in his home, and to figure out who’s going to pay for the housing, who’s going to pay for the care, who’s going to come in and provide the home services that he needs, and how do you do that within the very short period of time that those institutions, that have been serving him, want to discharge him? So one of the strategies that we’re really focused on, was access to information and referrals in an even-handed way, so people can know what’s available, and not just be discharged to a nursing home, when in fact they can be served well in the community. And to make sure that there is one place to go for that information that it’s not bifurcated either in the Medicaid program, as you apply for coverage, not one place to go for long-term care if you are going to a nursing home, and a different place to go for home and community-based care, but to also think about those options in a one-stop way. Also, a lot of work needs to be done on the workforce to make sure that you have the facilities available for people. The workforce available in the community, and as I mentioned before, really critical, is to have that person-centered care plan. And not to do it at the point of discharge, but really to back up and do it a lot before then.


We’ve highlighted a couple of case studies here, and I want to call out for this one-stop information and referral network, some of the things that Massachusetts had done through the benefit of the Balancing Incentives Program, which was one of the initiatives that helped support long-term services and supports in the community, that was included in the Affordable Care Act. They expended this kind of choice counseling, they made it available in the community. They had a one-stop arrangement to provide that eligibility assistance, so people could think about their financing options; not over here for nursing home, and over here for home and community-based care. And they really supported the direct-care worker. And what you see is the results here being very intentional, being very focused on it, and obviously this wasn’t just from these three efforts — Massachusetts has been working on this for a while, but what you see is between 2009 and 2017, they went from 45% of the expenditures for long-term services and supports being in the community, to 74% of those expenditures being in the community. That’s savings for the state…of Commonwealth of Massachusetts — I’m from Massachusetts, I should know. But it’s also really enhancing quality of life.


I’m not going to go through some of the other strategies. We can talk about some of them, but a couple of things just to call out. Again, there’s no one size fits all; it is a very heterogeneous population. Also want to note the obvious, and it’s a little bit of the elephant in the room when you talk about long-term services and supports in the community, which is the need for housing. You go to a nursing home, and Medicaid pays for your housing, because they are paying for the room and board as a part of the nursing home rate payment. But you’re in the community — Medicaid does not pay for rent, and sometimes people with low incomes or people who are middle class, who become low income, because of the expenditures that long-term services and other healthcare has cost them, can no longer afford housing in the community. So the housing strategy very much is part of what states are grappling with, and we’ll hear that a little bit more from others on the panel.


So with that, why don’t I turn it to you?


SARAH DASH:  Great. And before Michelle starts, I just want to point out, if anyone is still looking for a seat, there are a couple of seats around the table, scattered throughout the room. Thanks.


MICHELLE HERMAN SOPER:  Thank you, Cindy.  I wanted to echo my thanks to the Alliance and Sarah for having us here today, and for generous support from the SCAN Foundation and the Milbank Memorial Fund. So thank you.


I’m going to talk about a couple — the second strategy that Cindy mentioned, which is advancing integration of LTSS. We focus on managed care approaches, just because that is the most prominent vehicle that’s really out there today. But we did want to note that there are other efforts, primarily through provider or delivery system-based initiatives that states and other stakeholders have undertaken to better integrate LTSS into their programs. But today, we’ll focus on managed care. Even though there are far fewer beneficiaries who use LTSS, enrolled in managed care programs, compared to other Medicaid beneficiaries, is these programs really have grown substantially in the last few years, nearly a third of states have some sort of managed care program for individuals who use LTSS and that’s up from about six states, less than ten years ago. So it really has grown.


We refer to these program as Managed LTSS, or MLTSS, and really the goal is by including all services under one accountable entity, with one capitation rate, to reduce fragmentation across services, ideally to help with re-balancing, expanding access to community-based services, usually through some sort of incentive that plans receive to provide care in the community. And also to provide more cost-effective approach, and some budget predictability for states as well. Quickly, CMS recognized MLTSS for the first time in their major Medicaid Managed Care regulation update in 2016, which added specific expectation for plans, and also some consumer protections, which have been really important in driving some planning and programs forward. And I know Cindy talked a lot about the heterogeneity of the populations, and of the states that the state programs that are put into place, and that is really important in these programs too — although from an integration perspective, I would say a common theme is to really figure out how to make one entity accountable for providing a whole host of services.


In the interest of time, I think I will skip over this slide, and talk a little bit about the three strategies that we focused on in the toolkit for better integrating LTSS. The first one focuses on integration of Medicare and Medicaid benefits. Really, the impetus for this is to better align Medicare and Medicaid to improve service delivery, financing, and administration of both programs. Medicare/Medicaid enrollees are dually eligible beneficiaries, are as a population very high need, have very complex clinical profiles, and also must navigate between two systems with different benefits, different program rules, and different ways of governing their care. And that can cause a lot of confusion, a lot of fragmentation. There are several gaps in care, and it’s a rough path to have to navigate.


One of the ways that states are improving the system, is through contracts with Medicare Advantage Dual Eligible Special Needs plans. These plans, D-SNPs, enroll only dual-eligibles and are required to sign contracts with all of the states in which they participate. And states have discretion as to which, if any, plans to sign contract with, and also, what the requirements on those contracts, above the minimum threshold, must be. One of the most effective requirements that a few states have put into place, is to require a D-SNP to offer a Medicaid MLTSS plan through the same plan, so that individuals who have Medicare and Medicaid, have the opportunity to enroll in the same plan. I think Tom will probably talk about his experience in Arizona there, but states can really — a few states have been very ambitious with their D-SNP contracting, as a very specific way to drive integration. Other requirements that states can put into these contracts include, care management coordination, other alignment of administrative policies and procedures, and data sharing, so that states have information on the individuals enrolled in these plans. The results are — there is limited information on these programs, there is a very noteworthy study that came out of Minnesota a year or two ago, that shows that compared to a Medicaid only plan, their integrated product had pretty significant findings with regards to lowering hospitalizations, improving home and community based care, and primary care utilization, and lowering emergency room department cost and utilization.


Also wanted to note that we did not cover the financial alignment demonstrations, which are demonstrations that were created by the Medicare/Medicaid coordination office at CMS in 2011. There are ten states that use managed care to test a very highly integrated Medicare/Medicaid platform with joint federal and state oversight. These demonstrations have been incredibly ambitious, and they have been really a driving force for other states to use D-SNPs or other methods to encourage integration. But because the opportunity to participate in these demonstrations is over, we didn’t focus on it as a strategy in the toolkit.


I should also say, and this is actually true — I will make the point now — true for all of these different managed care arrangements; there are some early promising results, and states are very invested in making these programs work. There have been some challenges and these are not easy programs to launch. Several adjustments to payment rates, to care plans, to systems — processing enrollment, processing provider payments, have had to take place. So I should say that implementation of those programs have not been seamless, but states are continuing to work in partnership with CMS as well to continue to make them work even better.


The next strategy is focused on using MLTSS as a vehicle to integrate benefits for a Medicaid-only population. So very similar to the example that I just walked through, it’s providing physical health, behavioral health, and long-term services and supports under one plan. Many states use 1115 Medicaid waivers to put these programs into place, and there are multiple other waiver authorities mentioned on the slide too that they can use as well.


Again, limited information about these programs overall. CHCS did a study with [NASOed] last year, that looked at 12 states that have MLTSS programs and did find that several states reported improvements in health outcomes, improvement in self-reported quality of life, some decreased hospitalization and hospital stays, better re-balancing numbers. Many states said that the plans had achieved the goals that were set forward in their programs, and more budget predictability. So again, these programs require very close oversight and monitoring from states, and the states that have just launched, I would say they are working through developing these programs, but there are some really early, promising results. We featured Virginia as an example in the toolkit, and I should also backup and say, we featured Arizona and New Jersey as best practice states in our toolkit, but because we have Tom here, I’m certainly not going to talk about Arizona’s program. I will leave that to Tom. Virginia launched a state-wide Medicaid MLTSS program based on the legislative mandate that wanted to expand coordinated care to LTSS users across the state. They based the program on their financial alignment demonstration, and were able to sort of harness a lot of the good work that they did before. They had just launched, and have been really well. Very busy, but they’ve been doing really well.


The last strategy is to enroll individuals with intellectual and developmental disabilities in managed care. Of all of the populations and services that tend to be carved out of managed care most frequently, this is probably the most frequent. These programs have a whole new set of services in addition to what you would think about as traditional LTSS to provide employment support, and other community integration supports, which are really, really important, particularly to the advocacy community, and the families of members in these programs. Most of these programs use 1115 waivers to launch them, and like I said, there are only a handful of states that have done so far. These programs tend to move slowly. Again, they’ve had a lot of consumer and family, and advocacy engagement in these programs, and you know, the states I think that have had a lot of success have done it in a phased-in approach to make sure that all of these needs are being met. We featured New York in the toolkit. They have about 20,000 people voluntarily enrolled in managed care from this population for acute care benefits, and they are moving slowly to migrate their home and community-based services over to a managed care contract as well.


We highlighted some lessons here. I will probably go through them very quickly. That we came from the best practices from the states we interviewed — the state innovators. Ongoing targeted beneficiary, provider state agency, legislative stakeholder engagement was key in every area of the program. Continued provider education, continual feedback — a feedback loop from the beneficiary community was so important. So that really came up again and again. Defining your program goals early on and making sure you have a baseline data across utilization and cost and health outcomes, so you have a pre and a post comparison that you can make once the program launched. This is something that several states we spoke to said that they haven’t done, and they wish that they did to have a stronger comparison. And then continuing to collect data for program management purposes was really important. From an implementation perspective, making sure that you have sufficient resources, both money and the staff that are experts in different areas to provide the necessary services. Again, I mentioned this before, a lot of states talked about phasing in their programs, whether it’s by geographic location or enrolling population, you know, are another process to make sure that you’re gaining experience and can troubleshoot some of the issues that come up.


Just quickly, we listed a few strategies specific to different programs and I would say the one that stuck out the most that was specific to a strategy was on the Medicare/Medicaid integration piece, which was make sure that your state staff has some sort of Medicare expertise or access to education, because that’s really important.


Then just to conclude our session on the toolkit, there is really no one size fits all approach. States said they developed their strategies, they took stock of where they were, what their challenges were, what their opportunities were, to whatever extent they were able to embed LTSS reforms and other Medicaid reforms. Medicaid improvement activities were great. We had a couple of other key lessons — I’ve been through some of these already — stakeholder engagement is key across the program, investing in your program is really important, investing in federal partnerships, and knowing how you want to work with CMS in doing what you can to sustain that relationship is really important. And then lately, just thinking long-term. So I think we’ve heard comments already today about this aging population that the demand for LTSS is not going away anytime soon, and it will probably increase as people get older, and people are served longer in the community. So what is a strategy that can transcend administrations or program staff, or priority that’s really in place to make sure that you’re meeting the increased demands of this population. And that was really, really important. We are launching a state-learning collaborative with a couple of states to work on new reform strategies, and we’ll be updating the toolkit, and we also have a webinar coming up on March 6th. If you’re interested in more detail, you can find information there on the CHCS website. Thank you.


SARAH DASH:   Thank you, Cindy and Michell for describing the best practices, and now we’re going to turn to Tom, who’s going to talk about how this works in real life.


TOM BETLACH:  Good afternoon. Well, it’s a pleasure to be here, coming to Washington D.C. in February is always a good reminder why I love Phoenix, Arizona. Also, I will apologize in advance if I break out in song because I finally got to see Hamilton over the weekend, and that music just sticks in your brain. And third, I have the challenge of communicating 16 years’ worth of experience over to you all in eight minutes.


We are going to roll through some information pretty quickly in terms of some of the things that have gone in Arizona over the last several years. From a Medicaid Director, Medicaid program perspective, I think one of the things that’s the most important aspects that we need to be thinking about, is system design. And it may shock everybody in this room, but we’ve actually created a very suboptimal system design to serve individuals that require long-term services and supports. First of all, it started at the federal level to do creation of Medicare and Medicaid as being completely separate programs that serve some services for these individuals, and that historically did a pretty lousy job of communicating and coordinating with each other. That was exacerbated at the state level, where we often times have different state agencies responsible for delivering certain services. So a state agency may have Medicaid physical health in one area, and long-term services and supports for an aging population in a different area. And individuals with developmental disabilities in a different area. So trying to bring some sense to that fragmentation that exists both at the federal level in terms of the policy framework, and state level, is critically important, I think, in terms of coming up with some system of rational to better serve individuals that require long-term services and supports.


You have to think about it from a variety of aspects:  The first is, what authority are you going to leverage? Are you going to look at leveraging an 1115 waiver? Are you going to look at establishing 1915 waivers that have more coherence to them? The next is:  What is your structure within the delivery system? In Arizona, we’ve implemented managed care for serving members with long-term services and supports for the last three decades. We found that the model is much easier in terms of being able to integrate the full array of services. We’ve also found managed care to have more flexibility to be able to go out and expand the network capacity in a way that state government often has difficulties doing because of our rigidity around procurement and other processes.


Another important aspect in terms of serving this population, is having robust case management. And states need to be thoughtful around that, in terms of looking at what type of infrastructure and requirements exist as it relates to case management and care management. Michelle touched on the importance of duals and really looking at a system design around better serving the population. When we look at Arizona for our elderly and physically disabled population, 85% of that population are dual eligible members. For individuals with developmental disabilities, 30% of that population are dual eligible members. So what are we doing in terms of trying to bring those systems together under the framework of system design within the Medicaid space? Engaging stakeholders is critically important in terms of looking at members, families, other providers that come into that system, and having infrastructure around that, so that you are always getting that continued feedback of what’s working, what’s not working, within a system.


Then, I think, at the end of the day, what makes improvement within the LTSS space so challenging, is it really has to be an incremental strategy. There’s not something that you’re going to launch that’s going to be a huge initiative in which you’re going to dramatically change the delivery system overnight. It’s really got to be a thoughtful process that’s laid out over the course of many years in terms of changing the outcomes for this population.


So just touching on some additional information that really lays out more detail on some of the topics that I covered. So GAO came out with a report a few years ago, it identified that 5% of the Medicaid population equals 50% of the cost, which is not a surprise when you look at insurance products. But I think what’s interesting, is when you look at the last line, long-term care, what this line tells you is for those individuals that are in that top 5%, and a significant portion of the top 5% of those individuals that are receiving long-term services, you can see other diagnosis that they had. So 12.5% had asthma. But what’s really interesting is, look at mental health — 74% had mental health needs. And 24% had substance use disorder. Yet, in many states, we’ve carved out the delivery of behavioral health services, separate and aside from the delivery of long-term services and supports, and sometimes separate and aside from the delivery of physical health services. Again, when you look at individuals holistically, it comes back to that issue of system design, and what are we really doing to try and provide a comprehensive array of coordinated services to better serve the population?


Cindy touched on costs and the fact that the long-term care population and those individuals receiving long-term services and supports, are such a significant portion of the overall Medicaid budget. And you see here, just in Arizona, our overall population is a little over $5,000. Those individuals that are in their long-term care program are over $35,000 on a per member, per year. That’s just the Medicaid spend, right? There’s Medicare expenditures on top of that for this population.


What does it look like in terms of the system design, and really integrating care for individuals? Well, it looks like, in Arizona, having a managed care organization with robust case management wrapped around that number, and really providing, and responsible for the full array of services, and as Cindy mentioned, even extending beyond Medicaid where possible, in terms of trying to identify housing and employment support services for the population. Crisis services, which are so incredibly important, as well as bringing Medicare to the table in terms of addressing that as part of your strategy.


I mentioned this really being an incremental approach, and so here you get Arizona’s view of what our population has been for the elderly and physically disabled population, and the transition in terms of moving from nursing facility, which is where everybody was at the beginning of our program, to today, where 75% of our population resides in the home and community, and receiving services there. And so really, it’s been transformational, but it’s a three decade transformation and it’s not something that we’ve been able to institute overnight, but we’ve had to have consistent, thoughtful strategies around how we’re going to move this forward.


This is the national data that’s produced by MACPAC, and it looks at where we’re at, and we’re past that point now, we’re over 50% of our expenses nationally for home and community-based services versus the nursing facilities and the institutions. And so you see here, while you’ve got some states that are in the 70 to 80% range, there’s still a lot of opportunity for policy makers to be thinking about, how do we bring some of those other states along? And there is incredible pressure on some of those states in terms of dealing with nursing facilities and other stakeholder concerns around making these types of transformations, and we need to acknowledge that and identify that, and then identify policies that really can help align incentives in terms of continuing our progress forward around long-term services and supports.


We’ve made tremendous progress on duals and really trying to be more thoughtful around duals over the last six years or so. More progress really in the last six years, than in the previous 45 years put together around trying to identify and come up with programs to better serve dual eligible members. And here you see really two of the platforms that have been used:  Dual special needs plans, which was mentioned by Michelle, along with the demonstration programs for those states that have participated. I know often times folks bring up pace as a model in terms of looking at the duals, but just to put it up there for perspective purposes, it doesn’t even show up on the slide, because it’s 40,000 individuals nationally, as compared to the over 400,000 people that are in the demonstration and roughly two million individuals in dual special needs plans.


In Arizona, again, looking at serving individuals that require long-term services and supports, really thinking about duals, we’ve tried to leverage the dual special needs plan platform for the last decade, and so we were pleased to see Congress make that permanent in terms of going forward, and being a viable platform by which states can integrate services for dually eligible members. And so for us, we’ve leveraged the ability that states have had in terms of that contract with D-SNP plans, we have told organizations in the state of Arizona, you are not going to get a D-SNP contract unless you have a contract with the state Medicaid program to deliver Medicaid services. So we’ve really appreciated the flexibility around that, provided by federal partners, and have really tried to move the ball forward. In addition, we’ve leveraged seamless conversion in a way that’s been very positive. So seamless conversion, which is going through the process of being renamed to default enrollment through some proposed rules, is the ability to say, if you’re Medicaid enrolled, and you are becoming Medicare eligible, you’ll be enrolled with a dual special needs plan in which we can align the benefit. You have plenty of opportunities to opt out, but in Arizona, we’ve had over 7,000 individuals move into an aligned status with about 10% dropping out through that process. So great retention. Individuals have been happy to be able to go into a system in which they have a singular plan that is providing all of the services for them. So it’s a real opportunity by which states can continue to align the delivery system for individuals that are dual eligible.


Michelle already touched on this, so I won’t spend any time on it, but it’s just some of the data around the success stories that have been quantified in Minnesota and Arizona and other places in terms of alignment.


In conclusion, this is really an incremental change process in terms of the transformation. It’s not occurring overnight, but it’s something that we need to be thoughtful about how we’re going to move the system forward. For us, managed care has been a key in terms of leveraging that flexibility for that delivery system, and then again, the opportunities at the federal level to continue to leverage D-SNP platform, and then continue to look at incentives, because where we have, in terms of things like money follow the person, has been very successful in continuing that transformation for this population.


BROR HUTGREN:  Great, thank you, Tom. Well, good afternoon, I’m really pleased to be able to be here this afternoon to provide the health plan perspective on this topic. I’ve had the opportunity to have worked in and around long-term care, and long-term supports and services for over a decade in several states, and it’s been an interesting ride.


What I want to maybe start with is just saying, from a health plan perspective, implementing and managing long-term supports and services is hard. It’s hard, it takes a lot of work, it takes a lot of commitment to the population, to commitment to investment, commitment to the long view of system change. You saw the graph that Tom shared that shows over time, we can make a big difference in people’s lives, helping people live in their homes longer, helping people return back to their communities. Really good stuff. Doesn’t happen overnight. Doesn’t happen overnight for a state, doesn’t happen overnight for the plans that implementing, and it’s difficult. So a couple of things that we’ve identified that are really critical to success:  It comes down to partnership and transparency. Partnership around program design; partnership around understanding program goals and objectives, stakeholder engagement, being able to cast a wide net around the entire community, and understand concerns and fears. When you implement managed long-term care, there is a lot of fear in the community. Fear of losing benefits. We’re talking about services that are essential to people being able to live day-to-day, like we all like to live. The ability to get up, be independent, be able to bathe, to eat, to cool. All of those services are very personal. So when you talk about introducing managed care into that mix, there’s a lot of concern. So as a managed care entity, we need to understand that, we need to be clear about our goals and our intentions, and understand that we’re hearing our community stakeholders in that process.


I just want to start with that as a way to think about managed care from our perspective. It does take time and energy and commitment to the population. So with that, why would a state want to work with a managed care entity and actually delve into this very difficult opportunity to transition into their system? One is sustainability. We’ve heard a lot about the opportunity to re-balance the system to whatever it was or perhaps better than it was. The reality is, a nursing home is a costly place to provide care. It’s also a sub-optimal place to provide care for many people. Often times, the nursing home has become the place of last resort. We heard about the circumstance where someone is admitted to an acute hospital, they are discharged to SNF, it’s a lot of work to figure out how to get someone back into the community, so they end up in a long-term care setting, spending down their assets, and ultimately becoming a long-term resident of a nursing home. Most of those individuals would rather live in their own homes. And my experience over the years is, if you can help people find a way back home once they’re in a nursing home, but more importantly help people stay in their homes longer, you are doing a tremendous service to that individual, but you’re also saving significant dollars to create sustainability for the state. On average, you are looking at a nursing home costing between three to five times the amount that it costs to maintain someone in their home. That’s going to vary based on the individual and the market, but in general, much more sustainable. What managed care does is it gives the states a vehicle to prime the pump. They can say to a managed care organization, we believe you can shift the dependence on nursing home down over the next three years. We are going to pay you an amount that reflects that change. So now, the state has been able to take some savings, invest that in infrastructure that’s required to be able to move the system forward, and then have that long-term care managed care organization essentially on the hook to help promote that system change. And that creates sustainability for the states.


Secondly, flexibility. You heard several of the speakers talk about this. Medicaid and Medicare are not known for being flexible in the way they pay for services. There is a defined benefit. If you provide the service, you get paid a defined amount. Under MLTSS managed care, the managed care organizations are provided flexibility oftentimes to provide services that can be beneficial in lieu of a nursing home placement. So if you can provide a service that’s less costly, and more effective, you can provide that service and keep people in their homes longer.


Third, accountability. Having an entity that is responsible and accountable for delivering on your state objectives, for your beneficiaries, your citizens, provides you a great vehicle for driving quality, driving improvement and outcomes, driving personal satisfaction for your beneficiaries. Managed care organizations are held to high standards around those goals. Sometimes it’s as simple as timely claims payment. It doesn’t sound like much, but again, it takes away from some of the fear as you are implementing big system change.


How do we tackle this? You’ve heard a lot about the integration of Medicare and Medicaid. The inclusion of broad populations is essential. So when we think about really making a difference in managed long term care, having a broad base of Medicaid beneficiaries, and access to their Medicare data, even if only we have their secondary Medicaid payment, we can start to identify when someone has a change in condition, change of medications, in-patient admissions, frequent ER admissions, that may be indicative of some change in condition that allows us to engage differently, risk stratify differently, and be able to find people who are not yet in the nursing home, who may be moving down that path. We’ve all seen our parents aging, seeing those changes. If we can identify that from medical and behavioral claims data, it allows us to intervene differently than we would if we were just looking at that long-term care benefit.


Second, Tom mentioned the strong care management; we call that service coordination. It’s the heart of the model. Having the ability to sit down with each and every one of the people we serve, and have an in-depth conversation around their needs, their personal wishes, and what they need to have in place to be able to live independently, creating that individualized person-centered care plan that is going to cross over. It’s not just medical, we are talking about behavioral, social, functional needs that we would then help coordinate whether or not we are paying for that service. That is critical in maintaining people in their homes. And then again, access and quality improvement. You also heard this reference several times. When you start to see a state implement Medicaid, managed long-term supports and services, many of the things that are needed to maintain, or change that system, may not be in place. Managed long term care entities can begin to build capacity to be able to provide incentives to providers to build out where there may be gaps in service, and also to think creatively around how to incent providers to cross over from long-term care into addressing some of the acute care needs that these individuals also have.


And then finally, I think it’s really worth noting that — well, maybe two things here — the people we’re talking about are not just the elderly. We’re talking about a broad range of individuals that include a large number of elderly, but also include adults with chronic and disabling conditions. Also include individuals with developmental and intellectual disabilities. The way that we serve these individuals in their communities will be much different than a traditional medical model. This entails whether coordinating services around transportation, personal attendant care services — again, people that come into the homes to help with cooking, cleaning, bathing. All of those things again, that we depend upon every day to get ourselves out the door. Employment support, housing — housing is a big, big issue. When we look at the re-balancing opportunity, one of the biggest challenges in helping people transition from nursing home back to the community, is having affordable and supportive housing. Not all states provide assisted living as a Medicaid benefit. It creates a significant challenge in the ability to actually move people out of nursing homes, and back into their own communities. Again, it’s much easier, much more effective, if we can identify people in their own homes, work to sustain them in their own homes, and meet their needs in their own home. I want to be clear too that nursing homes are an essential part of the delivery system and always will be. They are going to serve people when they’re at that critical area of need. But I think there is so much more that we can do to organize our systems of care around those individuals to reduce that dependence, maintain that critical resource for those people that truly need it, and creates sustainability for the states in the process.


SARAH DASH:  Thank you so much, all, for your presentations. I think based on the comments, I feel like we should also have a State Housing Director up here to talk about…so let me kind of follow up on that point that I think all of you made about the need to integrate even beyond, and the flexibilities that are needed. How are states looking at that? Maybe Tom, or Bror, or Michelle or Cindy also want to weigh in, based on the states that you interviewed. There seems like such an overwhelming amount to deal with just within Medicaid. How do you deal with making those connections beyond to sort of surround the person with the care that they need?


TOM BETLACH:   So it is a challenge. One of the changes we’ve gone through in Arizona, and you’re seeing this occur more and more, is part of our integration efforts was a consolidation at the state level around policy making. And so we’ve integrated more policy making infrastructure into the state Medicaid program, which includes housing resources, employment resources, crisis resources, and it really gives us the ability to have a level of expertise in those areas that we never had before. It also came with some resources in terms of state’s commitment to housing for certain populations, along with better connectivity to the Housing Department. You mentioned the housing director. But really being able to look at trying to do more unique infrastructure deals with the state and leverage those resources as well. There is still not enough funding really available to address the true need in this area, but I think it’s important, and it’s really one of the larger changes I’ve seen within the managed care space occur over the last five years as this focus on social economic determinants, where we’ve got actually for-profit health plans that have come into our state and said, hey, we’ve got dollars on reserve in terms of the equity requirements, and we think there’s opportunities to invest that in low-income housing in the state as well. And United’s actually gone forward with a deal like that in Arizona. So I think there’s ways for states to try and be creative in terms of tapping a variety of different avenues, and trying to create resources around this.


SARAH DASH:  Thank you. So we have time now for some audience Q&A. You should have some green cards on your table, and if you haven’t already written out a question, you can so, and someone from our staff will come pick it up. You can also ask a question at one of the two mics. They are a little hard to see, but there is one on either side. And while we are gathering those questions, and as your getting ready to ask your questions at the mic, let me ask kind of a level setting question. Flexibility was a big theme here, and maybe for those who aren’t as familiar with the waiver process, let me ask:  Why do states need waivers to implement these kinds of changes? Or do they? Maybe it’s an obvious question to those of you in the audience, but could you talk about that and — Cindy, kick it off?  Thanks.


CINDY MANN:  Medicaid has multiple different authorities that are available for states to be able to implement long-term services and support solutions. In fact, and a proliferation of some of these authorities coming through the Affordable Care Act, as well as some funding that’s been invested, all of which has been very helpful, but it also is a little bit daunting. And certainly when a little bit of — when I was at CMS, and I think what we’re trying to do in this toolkit, is to have states think about what they want to do, and then let’s sort through what the different authorities are that they can take advantage of, to be able to accomplish their objectives. Lots of times you don’t necessarily need a waiver. Certainly not necessarily need an 1125, a comprehensive waiver. But historically, and this goes to the re-balancing/balancing question, Medicaid, the services to provide, or the authority for a state to draw down federal dollars to do care in home and community-based settings, often does require either a 1915C, which is a more constrained waiver authority, or potentially 1115 authority. In part, because states are often looking to go into this line of business with a little bit of financial security that the flood gates won’t open and sometimes the authority under the state plan, not using your waiver authority, will say, you can’t put a cap on the number of people covered. And some of the waiver approaches allow that. So there is lots of different authorities that the toolkit has a list of some of them, so you can look through them. They can be daunting. Many of them do overlap. Some of them have expired, some of them have continued, but the bottom line is there’s a good amount of flexibility that’s available, whether it’s through the normal state plan process, or through 1915C, or through 1115. But these require investments as well, and sometimes some of the funding streams that have been provided by Congress, they come and they go, and that causes states to have to figure out how to develop a sustainability plan on their financing.


SARAH DASH:  Thanks. Both of you have been very patient at the mic, but I’m going to ask a quick follow-up question, because I think it’s on this topic. I have already three cards asking about Money Follows The Person, and balancing incentive program and their expiration thereof. So maybe if you could comment a little bit on that, you know, how particularly many states use that money, and I don’t know if anyone else wants to comment, and then we will get to the questions at the mic.


CINDY MANN:  So Money Follows The Person. Authority is expiring, states are still using some of the dollars that they’ve had a for a while. It’s been a terrific source of funding for many, many years, that have allowed states to deal with some of the things that straight Medicaid funding won’t pay for under the statute. For example, you can use first month’s rent, security deposits through Money Follows the Person, so there is some discussion about extending MFP. But at the moment, states that have MFP funding are using the tail of what’s left in their funding. Still for important lessons learned going forward, but I know they would enjoy having a reauthorization of MFP.


TOM BETLACH:  And the delivery of some of those services actually can fall under that bucket of flexibility that managed care can have. So not every state is able to tap into that, but it is something by which you can leverage your MCO ability to be able to deliver some of those types of services.


CINDY MANN:  Yeah, it’s a really good point. There is a significant flexibility between the states and the managed care plans on how they use the Medicaid dollars that are provided to the managed care plans by the states, and that really has been a source of a lot of innovation over the last few years in particular.


SARAH DASH:  Thank you. Let me turn to the questioner at the mic. If you could introduce yourself and briefly state your question.


AUDIENCE MEMBER:   Hi, Barbara Gay, I’m from Leading Age. We represent long-term services and support provides including housing providers, so we’ve been glad to hear the discussion of housing. Just a comment, and then a question. I was interested, Tom, when you said how many years it’s taken to develop Arizona’s program, because in some other states, for example Kansas, when they went to put managed care into long-term services and supports, they expected to do it within a year, because they needed to get to a lower budget number for Medicaid. And as it turned out, that didn’t work out so well. I thought it was interesting and really beneficial for you to describe how long it takes. Then a question for Mr. Hutgren:  What we’ve found in a lot of states is that the managed care plans don’t really understand long-term services and supports, and how it’s different from managing primary and acute care. Could you discuss how United Healthcare went about learning the field, so to speak?


BROR HUTGREN:  Thank you, great question. So one of the frequent comments we have from stakeholders is, this is not a medical model, and it’s a really important point. When we start talking about delivery of services to individuals, it’s not about utilization management, it’s not about a medically driven model, it’s more about understanding the needs of each individual, and creating a care plan for that individual that reflects their needs and their desires. So we’ve gotten there — actually, we’re continuing to always strive to be better at that. But one of the big things is understanding the population, understanding the benefits, hiring people that have actually worked in the field, hiring people that have actually done service coordination, and maybe people that have a deep understanding of how services and supports work for individuals. So not necessarily taken an RN driven model out of a medical model. We hire social workers, RNs and other individuals that have qualifications to be able to understand and build those care plans. So it’s a culture issue, it’s a knowledge issue and it’s a clear understanding of the benefit structure and how it augments the medical components. I do want to add though, all of us including individuals in LTSS plans, have medical, behavioral, and social and functional needs. So when I think about the approach, it’s really a team-based approach that includes individuals that have medical expertise, individuals that have expertise in developing functional care plans, and functional supports, and individuals that have expertise in behavioral health, and bringing those individuals together for the people we’re serving. So it’s a team-based model that we try to deploy. I don’t know if that gets to your question or not, but it’s a tough thing to make the transition.


TOM BETLACH:  And I think the state plays a key role in that too, in terms of the development of the contract and what the expectations are in the managed care organizations. I mean, part of the success so much is driven by the framework, by which the state is also dictating how services will be delivered through that contract.


BROR HUTGEN: So in Arizona, Arizona actually has very specific requirements around the qualifications of our staff, around certain individuals that we serve.


CINDY MANN:   I just wanted to second the question. When you talk about best practices, and you highlight opportunities, you do tend to miss the point, which is really important, that this is hard and not all health plans are ready, not all home and community-based providers are ready, not all states are ready. Certainly not all consumers and their families are ready. It does take a while, and if the state is looking to immediately get — like, I’m going to get 15% savings in my next budget cycle if I suddenly put all of long-term care into managed care. Your probably looking for some trouble. So it really is a journey, and people’s lives are at stake, and so it’s really one that demands a lot of intention, a lot of care, a lot of conversation, and really putting consumers at the table. Not even just to provide feedback, but really to help design how things are structured from the beginning.


SARAH DASH:   Thank you for your patience, if you could introduce yourself.


AUDIENCE MEMBER:  Sure, I’m Claudia [name], I’m the Medicaid Director here in Washington D.C. A couple of things:  I had sort of a comment about MFP, and then I had a question for Tom and Bror. On MFP, while the demonstration has ended, states have had to submit to CMS sustainability plans, and I think one of the things we want to get to, is how do we replicate the services in MFP in the Medicaid program, not as a separate demonstration? And a couple of other things — and not every state can do managed care. We can’t do managed care here for our long-term population, our numbers are not big enough. So we are using admin claiming for Medicaid to support our ADRC to do transitional coordination as well as benefits application assistance. One thing that CMS does not let us do, and we wish they would change their interpretation and rules, is when someone is transitioning out of a nursing home, and they are applying for the waiver, we would like to be able to assign them a case manager while they are still in the nursing home, and pay that case manager to assist in that coordination, rather than have two different case managers working with that person, or if somebody is in the waiver and they have to go into a hospital short-term, CMS will not allow — they allow us to pay the case manager, but not while the person is actually in the hospital or the nursing home. They have to wait until the person gets out. And this is because CMS doesn’t want to pay twice for the same service. But if they change that rule and interpretation, we could have continuity of case management to assist in these transitions. So I don’t know if anybody from CMS is here, but I hope you’re listening.


My question for Tom and Bror is:  We’ve seen expediential growth in our costs for personal care assistance services. We probably have one of the more generous PCA benefits in the country, and we seem not to be able to ratchet it back in any way. In fact, we have many beneficiaries now who are in the community who are getting 24 PCA because they can’t be left alone, and they live alone. We are working on developing new assisted living units, and I’m excited about that, but until we get there, I’m curious, with the fact that you’re so reliant on managed care plans, how do you control, what mechanisms do you use to keep PCA hours and costs in check? What are you doing?


TOM BETLACH:  I don’t know that I can point to a specific set of tools. You know, just in looking at the overarching data, we haven’t seen an explosion in that service. I think some of that is the work that the managed care organizations are doing to help manage the delivery of those services. I will tell you that one of the areas that we’ve had overall number of staff, has decreased significantly. Our Office of Inspector General staff have grown pretty significantly, and obviously they do some work in this space around following up on leads and things like that, but I don’t have a specific list of strategies that I can point to, other than to say we continue to mine the data, and we haven’t seen that type of explosion in the services that you’re describing. So we can talk some more after.


AUDIENCE MEMBER:   We actually do an independent conflict-free assessment, so we know these people need the services.


TOM BETLACH:  Right, and we do too. Yep.


AUDIENCE MEMBER:  What do you do if someone’s in the community, and they really can’t be left alone? That’s the question.


SARAH DASH:   Let me follow-up on that question too, and just — Bror, maybe you want to weigh in, and talk a little more broadly about the workforce and the workforce needs and issues, and how states and managed care companies, and possibly the federal government, can deal with the workforce needs. Bror, I think you want to jump in. So you go first.


BROR HUTGREN:   Well, just on the PCA question. It is a reality, there are people that want to remain in their homes and do require significant and oftentimes 24 hour support. One question I would ask, are you delivering your PCA benefit to your state plan or at their waiver?




BROR HUTGREN:  Both, okay. And so thinking about how you structure your program to perhaps provide a tiered benefit level based on need, you can at least maybe create some gating that would go on, but the other non-magic bullet here is the looking for natural supports. Really trying to understand — do people have other — again, it’s not a solution, but that is part of our process, is really looking to see, are there natural supports? Are there other trade-offs that could be delivered? But it’s a reality that if you do not have, in the case of Arizona, where you’ve got a pretty robust assisted living — matured assisted living structure, you could oftentimes replace the need for that 24 hour PCA with some other support. But it really is going to probably come down to a program design discussion, and then a reality of, as we keep more complex people in their own homes longer, it’s not a simple cost savings analysis. There are people that desire for independence is going to come at a cost, and it is just one of trade-offs. So I don’t have an answer for you, other than to say, program design, natural supports, and really looking for benefit expansion around assisted living.


AUDIENCE MEMBER:   We’re doing the assisted living piece.


BROR HUTGREN:   And workforce. Workforce is a real issue, and not only from a PCA perspective. If you look at the growing demand for personal care, and the shrinking workforce, it is something that as a country, we’re going to have to grapple with in a big way. One of the really interesting dynamics I think we also face with people that provide paid and unpaid personal care, is the toll that it takes on that individual, both in terms of their health, their financial situations. So I do think as we look at these natural supports, that are — children of aging parents providing supports to their parents, that is creating a strain on those individuals that will create a bit of echo effect down the road, I think. So as a country, we need to grapple with, how do we support people actually who are providing that day to day care for complex individuals?


SARAH DASH:  Anyone else want to weigh in on the workforce or caregiver –?


TOM BETLACH:  Well, the only other issue around workforce, is really states also need to have strategies around whether their expectations are around the quality of that workforce. So are you going to have some centralized credentialing process? Or something that tracks the level of training within the staff that are part of the delivery system?


MICHELLE HERMAN SOPER:  I just want to say one of the things we’ve been doing some work on too, and this doesn’t get to the cost question, unfortunately, in fact it’s — this might add to it, but having an adequate workforce in place, having a well-trained workforce, and having a workforce that is motivated to want to continue to grow in their profession and having opportunities for some sort of career letter or some sort of recognition of the hard work that they are doing, is something that a lot of states are really focused on now, that as states are rebalancing and trying to spend more money in the community, part of that is also thinking about how they or the plans that they work with can reward the workforce for doing that hard work as well. So that’s something that I think we cover in the toolkit as well, and it’s a real issue.


CINDY MANN:   I’d like to comment on here. Let me point out one area of where states have been beginning to spend more time focusing on, is the natural supports that do exist for some people, certainly not everybody. And not to shift the requirements for caregiving to families that can’t sustain it, but to recognize where that caregiving is in fact in place, and the strains that it places on the caregiver, and on the family. And so to be able to — Washington State for example has gotten a waiver and is just beginning an initiative, which is outlined in our toolkit, around providing support for the caregiver at the home. To provide respite, backup services for that individual, so that they can sustain that situation at their — which is their wish, but to do it in a way that accommodates really the incredible amount of stress and strain that it often imposes on the family. But I also really want to stress the point that Michelle made about the pay. The pay rate is pretty low, and if we’re expecting people to have continuity, if we’re expecting people to be trained and to be able to continue and do this work, we need to recognize that it’s an area that we really have to look at our wage rates.


SARAH DASH:  Just kind of a quick check-in, we have about 10 minutes left for questions, and there is a bunch of really good questions here on the cards. But I know people are busy, we hope you’ll stay the whole time. If you have to go, please fill out your blue evaluation form in your packet before you go, because it really helps us improve our own quality.


So let me ask a question about quality, speaking of that. Can you talk a little more about data and quality reporting, and what we mean by that in this context, and what are some of the challenges, as well as maybe areas of progress?


TOM BETLACH:  Some of the challenges just exist with the system design. Challenges I discussed, where you have Medicare and Medicaid, in terms of two separate programs serving this population. And the measures that exist within the two spaces there. Also, when you look at Medicaid measures, many of them based upon HEDIS and other things like that, aren’t as applicable to this population. There needs to be more done about feedback from the individual and the family in terms of the types of services that they’re seeing. And then again, I think it’s important that we look at more real time information within the delivery system, and not something that’s coming two or three years later through measure sets. So this is clearly an evolving space as it relates to try and identify better outcome measures. But there needs to be more done as it relates to better serving this population.


BROR HUTGREN:  I think just to echo Tom’s comment, HEDIS is the easy measure. It’s easy, it’s not accurate necessarily, it doesn’t always reflect the outcomes for the population we’re serving. Many of the HEDIS measures are designed for healthier community-based individuals. Adding in goals around self-determination, the ability to live in the environment that people choose, the ability to have services provided in a respectful and meaningful way, are ways that we’re trying to expand our quality focus to look at, again, that person-centric approach. Can we actually measure how person-centric our approach is? And are we helping people live in line with what they would expect for their own goals and wishes? It’s challenging. And the other part, on the data side, and we know that 80% of this population is dual-eligible, so when we start looking at HEDIS measures, especially if you have a non-integrated system, it becomes very difficult to understand what’s actually happening on the medical side, what’s actually happening on the acute care side. You may get that information months after the fact. So I think getting to an integrated system, expanding past traditional HEDIS measures, and satisfaction measures, and self-determination measures, is the focus that I’d like to see us continue now.


SARAH DASH:   Let me try to move on, because we have a question at the mic. If you could be relatively brief with your question and answers, and then we have another one over there. That might be all we have time for, before we wrap it up, but we’ll see.


AUDIENCE MEMBER:  Carl Polzer and I’ve worked long-term care policy for several years, particularly with assisted living issues. So assisted living has been identified as the key to a lot of these issues. The middle ground between nursing homes, and living at home, but under Medicaid, it has been pointed out, housing isn’t covered, because it’s considered a home and community-based setting. The states usually use SSI for the basis to pay for housing and assisted living, about $8,000 or $9,000. The cost is somewhere double of that, depending on the state. So where do we get the housing money? If you’re United Healthcare, if you’re the State of Arizona, do we raise SSI for certain populations, for certain disabilities? What is the solution? That is a huge issue.


TOM BETLACH:  I would project out several years in terms of looking at the change and the evolution of the system. And we started with just an institutional base system that had nursing facility services provided. We’ve evolved to home and community-based services, we’ve recognized the limitations around housing. My guess is, there’s going to be an iteration in the future that will recognize for a certain set of the population. Some ability to leverage a housing funding stream. I’m not sure what that comes from, if it’s from Medicaid or some other funding stream, but if you really want to address the problem, that’s how the system has to evolve.


BROR HUTGREN:  One thing to add: We are experimenting with looking at, if we provide some support of housing for individuals that are very high risk, high cost, can we through providing that safe place, that stable place, and providing medical care, behavioral healthcare and social supports within that setting, can we actually reduce the medical and behavioral expenditures? So we are looking at that. That is a — it’s not sustainable in that fashion, but it will provide us with some really good data around the integration of a truly holistic approach, and using medical and behavior expense reductions to fund it short term. Long term, it’s got to be around a policy and a system change.


AUDIENCE MEMBER:   Hi, Erin [name] from the National Committee for quality assurance. One very quick comment, which is that I fully appreciate your comments on HEDIS and the lack of measures, and we actually have four measures of long-term services and supports for potential inclusion in HEDIS, so anyone would like to provide comment on those measures, they are up for public comment. But that’s my little personal plug. One of the big challenges we’ve had in measuring quality is that the populations, I think it’s been said many times here today, are very heterogeneous, but the ways in which they are heterogenous generally have to do with functional status, and functional ability, not just chronic conditions. Because the data we have available to us is primarily ICD data about chronic conditions that’s not telling us about their functional status. And we don’t have a way to understand from the data we have, what the functional status is of different people across different programs to be able to use that for measurement purposes, for risk adjustment, for identifying populations. Primarily, because we don’t have a unified way of assessing functional status yet. I’m just wondering how much that maybe has come into some of your work, and if you see any solutions towards being able to actually see functional status as something that we’re going to be able to measure more systematically in the future.


BROR HUTGREN:  We as part of our service coordination model do a comprehensive assessment of ADL’s and IDL’s, so we know for the population we serve, not only how many deficits in ADL and IDL that an individual may have, or how many strengths they may have, but also what those are. So I think there may be a way to get at that and at least sample to see, are there directionally some things that we could glean from that. So we honestly haven’t gone down the path of looking at which ADLs and IDLs tie back to which quality metric. We are really starting to look broadly at a framework for trying to measure quality in the LTSS and the IDD populations. But it’s an interesting point. I think there might be some people on my team that would be interested in talking about that.


MICHELLE HERMAN SOPER:  I would say that a lot of the states that we’ve worked with through some of our LTSS work, there are two states, Wisconsin and New York, that have unified functional assessments, and pull in this information into their quality strategy and their rate setting.  Many other states are moving in that direction, but haven’t yet, and there is a whole host of issues, many of which I’m sure you’re familiar with, with reliability and just the resources necessary, but there are states that have sort of been able to harness that, but it really is few and far between. But its not for lack of interest and agreement that getting a better understanding of how different functional limitations impact quality, impact payment, impact utilization, it’s something that a lot of states are really focused on better understanding.


SARAH DASH:  We’ve had a great discussion. There are still a lot of questions on the cards, and I’m sorry if I didn’t get to your question. I think we could extend the time of this briefing by another hour and a half, but I think that we’ve unfortunately started to run out of time. I do want to invite Chris Koller, who is president of MilBank Memorial Fund to come up and make some brief closing remarks. And if you could remember to fill out your blue evaluation forms before we head out for the day, that would be great. Thanks. Chris?


CHRIS KOLLER:   Thank you very much, Sarah. First I want to give thanks to the panelists and to the Alliance for Health Reform for putting together what was a very sophisticated conversation. We went through a lot in an hour and a half. The Fund, our mission is to improve population health by connecting leaders and decision makers with the best evidence and experience, like what we heard today. The leaders we focus on are really at the state level. Our state guys that we work with, told us to pay attention to long-term services and supports, and so we went out looking for partners. That’s why we’re very happy to team up with Bruce and his team at SCAN, as well as Cindy, and her folk at Manatt. And Michelle, and her colleagues at the Center for Healthcare Strategies.


I took away — you could have a lot more than this, but Sarah only gave me a little bit time. I took away three things from this:  If you are a junkie about state-based innovation, long-term services and supports is the place to do it. What’s in the toolkit that CHCS and Manatt put together, what Tom and the folks at United are doing, is really hard stuff, and there is a lot of really exciting work going on at the states.


I want to call up one of the strategies that is identified in the toolkit that Michelle referred to, which is the pre-Medicaid strategy. We know the path here. The path for Medicaid eligibility for long-term services and supports is chronic illness, serious illness, hospitalization, nursing home, bankruptcy, or financial eligibility, Medicaid. And until we figure out how to assemble services and help families before that, we are facing a real problem.


And then the last pieces is the importance — it’s a little bit overplayed, but the notion of the state-federal partnership. Tom and his colleagues, all the folks in state work, we heard from the folks in D.C., need a lot of help doing this work. There are opportunities at CMS around waiver negotiations, around the work with duals. There are opportunities for other federal agencies around quality measures and accountability.  This whole idea of what does it mean to be patient-centered, not every stakeholder in the LTSS argument is a consumer. There are lots of other stakeholders who might have some particular financial interests going on. And then the important activity that Congress does:  Reauthorization, permanent authorization last week of D-SNPs, the discussions going on now about Money Follows the Person. But LTSS is 30% of the Medicaid dollars. Demography is destiny, it’s only going to go up. And this is an area where the challenges are not particularly partisan, they are technical. They are bigger than the partisan challenges, so it creates a great opportunity to work on it.
So thank you very much for your time.




SARAH DASH:  Thank you, Chris, and thank you again to Bruce Chernof of the SCAN Foundation. Please join me in thanking our panelists for today.