The most important trend in care for the frail elderly and younger people with disabilities may be what’s called managed long-term supports and services, or MLTSS. This effort to combine medical care with long-term care would replace today’s disorganized, ineffective, and even dangerous system with one that can bring together complex care that’s being delivered by many different providers.
Done well, this model has the potential to improve the quality of life for those receiving care and save money. Done poorly, it puts an extremely vulnerable population at even greater risk than it is today–and may not save money.
For a paper on MLTSS just published by the Catholic Health Association of the United States, I had a chance to look at very different models in New York State and Florida. However, more than 20 states are in various stages of adopting this system.
Many are beginning to coordinate medical care and supports and services for those who are eligible for both Medicare and Medicaid. These are often low-income people with disabilities, including many frail elderly. While some states have slowed their efforts, 2014 looks to be a watershed year for these programs as states such as New York and California begin fully coordinated care programs.
These are officially designed as temporary demonstration projects but in reality they will be extremely broad in scope. California, for example, expects to enroll 450,000 people—nearly half of its dual eligible population—this year.
In effect, states are turning over full responsibility for a patient’s health to a managed care organization (MCO). These may be insurance companies or health systems and involve partnerships among hospitals, physicians, nursing facilities, home care agencies, and case managers.
Fully managing care for seniors and others often means redesigning both the payment and delivery systems. In one model, providers are paid a fixed, per-member-per-month capitated payment, much like an HMO or hospice. If they can provide care for less than that rate, they keep the difference. If care is more costly, they are at risk for extra expenses. And–a key element– if they don’t meet specific quality goals they lose some of their payment.
How does it work? Imagine an 85-year-old living alone with congestive heart failure. Uncontrolled, her heart disease may send her to the hospital two or three times a year—trips that are both risky for her and costly to the system. Today, her doctors are focused on prescribing medications to control her CHF but may unaware of her personal care needs. Does she need an aide to help her get started in the morning, or to weigh her, or cook healthy meals? Does she need a ride to her medical appointments or help managing her medications?
Traditional Medicare won’t pay the relatively low cost of providing these services. Yet, it pays to repeatedly hospitalize this woman. For its part, Medicaid would pay for some personal care services, but not all of them. And if they avoided hospitalizations, all of the cost savings would go to Medicare. The states would get nothing.
In a managed care model, an MCO is paid by both Medicare and Medicaid and is responsible for all of this CHF patient’s care. If the safest and most cost-effective solution is an aide, a taxi ride, and a wireless scale, the MCO would make it happen—and reap the financial benefits from avoiding those hospitalizations.
Make no mistake, this isn’t simple. Patients often have multiple, complicated chronic conditions. Getting docs, hospitals, and long-term care providers to pull together is hard even when their financial incentives are aligned. But the model at least has the potential to improve care for those with chronic illness or injury.
If it works, don’t be surprised to see it expanded to include Medicare managed care, or Medicare Advantage, members.