1. Trends & Transitions: Future for Long Term Care
Tom Wilfong
VP Medicare Medicaid Programs
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2. LTSS Goals
Improve health outcomes through integration of all health care services
Focus on living independently in the community
Provide the right amount of services at the right time in the right setting
Help the state obtain budget predictability and savings 2
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3. Who We Are
WellPoint has over 16 years of experience in managed Long Term Services and Support (LTSS) programs
WellPoint serves over 350,000 SSI members and provides over 60,000 members with managed LTSS services in seven states
Our care coordination staff is experienced and knowledgeable in providing the right care and services to our members using automated tools and systems 3
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4. Value Proposition of Integrated MLTSS Program
Members
Providers
State
Increase in access to care
Improves health outcomes
Higher satisfaction with health care
Stable and/or improved functional ability
Increases in community- based services to support independent living
Potential to eliminate the waiting list
Easier system to navigate with all services integrated
Increases support for family members and caregivers
Increases support for members with chronic conditions
Increases availability of services & coordination of care
Reduces administrative burden
Increases provider satisfaction
Improves quality results
Increases nursing home diversions
Decreases institutional care and increases community care & settings
Reliable health care data on results of members and plans
Accountability for all health care of members
Eliminates fragmented and duplicative services
Provides budget certainty
Savings in tax dollars 4
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5. What Are Other States Doing?
Plan Design
Best Practices 5
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6. Types of Integrated Programs in Other States
LTSS with Primary and Acute Care
Dual Integration for Medicare and Medicaid
Texas
Tennessee
Kansas*
New York
Florida
California
New Jersey
Virginia
California
New York
Texas
*(Includes Physically Disabled, Older Adults, Intellectual and Developmentally Disabled, Nursing Facilities, and Self-direction)
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7. Managed Long Term Care: Quality Improvements and Cost Savings
Texas STAR + PLUS Program
38% increase - members accessing community-based adult day care
32% increase - members accessing personal assistant services
28% decrease - inpatient length of stay
Average length of stay reduced from 7.39 days under FFS Medicaid to days
40% decrease - ER utilization
1505 members were diverted from entering nursing homes
1186 individuals have transitioned from nursing homes to the community
Savings of $123 million = $92 per member per month = 17 percent below FFS projections
Sources: Texas A&M Public Policy Research Institute independent assessment and State of Texas staff report as documented in: “Medicaid Managed Care Cost Savings: A Synthesis of Fourteen Studies.” (Lewin Group, July 2004.)
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8. Managed Long Term Care: Quality Improvements and Cost Savings
New York MLTC
Quality Performance Results from Year 1:
70% of enrollees received the annual flu shot
80% of enrollees had no reported falls in the past six months
80% of enrollees’ overall functional ability was stable or improved over a six or 12-month period
Less than 2% of enrollees were admitted to NFs
86% rated their care manager as good or excellent
WellPoint performed better than the state expected on successfully avoiding hospitalizations
84% of enrollees rated their health plan as good or excellent 8
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9. Tennessee Choices Membership: 2010 thru 2013
82%
57%
Group 1
Member who are receiving Medicaid-reimbursed care in a NF.
Members can be eligible for Medicaid in ANY eligibility category regardless of age or condition, so long as such persons meet NF LOC.
Member must have completed the PASRR process – and have been determined suitable for NF placement.
There are NO limitations on the number of members who can be enrolled in Group 1.
Within Group 1 – there are two sub-groups:
Group 1a – Members who are receiving Level I (or intermediate) NF services.
Group 1b – Members who are receiving Level II (or skilled) NF services.
March
2010
December 2010
December 2011
December 2013
Note:
Group 1=Nursing Facility members
Group 2 and 3= HCBS members
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10. Service Coordination Workflow
Reassess and Evaluate
Service coordinators contact the member and reassess his or her needs and functional capabilities
Service coordinators and members evaluate and revise service plans as needed
Identify Needs
Members are contacted and screened for complex needs and high-risk conditions as soon as possible
Members with complex and high-risk conditions and LTSS members are identified for a home visit
Identify
Needs
WellPoint
Service Delivery
Members select providers from our network
Service coordinators work with our care team to authorize and deliver services
Service coordinators ensure all appropriate services are authorized and delivered according to service plans
Service Plan
Service coordinators:
Make home visits and conduct comprehensive assessments of all medical, behavioral, social and functional needs
Work with a team of experts to develop service plans to meet members’ needs
Contact members’ primary care physicians for concurrence
Members and members’ families review and sign all service plans
Family Members
Service Plan
Reassess and Evaluate
CBOs
Providers
Service Delivery
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11. What Are the Necessary Steps?
Making the case for change
State Spending on LTC
5 year projections
Identify potential savings
Waiver discussions with CMS
Engage stakeholders
Legislature, agencies, advocates, individuals and families, providers, and health plans
Create participatory process for input and review
Design program
Maximize integration of services
Learn from other states
Texas, New Mexico, Florida, Virginia, New York,
Massachusetts, Arizona, Tennessee
12 - Month Process
Develop RFP
Solicit input to a draft
Issue RFP
Issue RFP and award bid
Readiness Review for Go Live
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12. Summary: Benefits to the State of an Integrated Managed Care Program
Improved health care outcomes and quality performance
More clients living in the community and fewer in institutions
Potential to eliminate the waiting list for the waivers
More clients getting access to primary and
preventive care
Less use of ER and hospital care
Access to all long term services and support
that includes all services in one program
Higher client and provider satisfaction with the
Medicaid program
Long-term budget predictability for the state with
all clients and services in a managed care system
Projected savings for the state: $ million
over 5 years 12
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