“We don't hear complaints about this often” Erhardt Preitauer, CEO of Horizon NJ said. “We are focused on making sure people get the necessary care that they need.”
Other plans also defended the MLTSS concept. “LTSS delivered through the fee-for-service system can be siloed, since they are not designed to include comprehensive coordination among the array of providers serving the individual,” said Merrill Friedman, director of Disability Policy Engagement at Anthem, parent company of Amerigroup.
“This can cause fragmentation that often leads to undue stress, unnecessary duplication of services, and unidentified and unmet needs that can result in poorer health outcomes for individuals.”
But complaints about loss of services aren't only noted in New Jersey. The National Council on Disability, a federal agency that advises the White House and Congress, turned up numerous complaints over the past two years at the 10 community forums it hosted around the country.
A common complaint was about lost access to care. Participants reported that the Medicaid managed-care organizations (MCOs) running the programs frequently deny long-term care services and supports that were previously provided under the Medicaid fee-for-service system.
“The impression is that some MCOs are very strategic in their denials and that other plans might just be careless,” NCD said in its final report. “But the way it plays out for people in MLTSS plans is the same—services are cut substantially without notice and explanation.”
States insist such cases are rare and that care for disabled Medicaid beneficiaries improves under MLTSS. New Jersey officials acknowledged that some may face a cut in service hours, but there are strong appeal procedures in place if there is a concern about impact on care. There have also been instances where services have increased as a result of the new program, according to Nancy Day, deputy director at the New Jersey Department of Human Services, Division of Aging Services.
The state also says the program is keeping people in the community. There are now 48,000 people getting MLTSS, and 30,000 are in the community, up 12% since launch.
Managed care for long-term support clearly can save Medicaid money. The median annual cost for nursing facility care nationally was $91,250 last year compared with $45,800 for one year of home health aide services, according to Kaiser Family Foundation.
Tennessee also claims success for its MLTSS program, dubbed CHOICES, which was launched in 2010. In the year before the program launch, only 9.75% of LTSS expenditures for older adults and adults with physical disabilities were home- and community-based. By the end of fiscal 2015, that had more than doubled to 20.06%.
One factor behind the state's success is that the plans offering MLTSS coverage in Tennessee are addressing the key issue of access to adequate and affordable housing for the developmentally disabled and others in need of long-term support. While Medicaid law prohibits plans from paying directly for housing, payers can connect their enrollees with providers that own housing or, in some cases, place individuals in homes of people willing to rent rooms to those who are less fortunate.
“Having a place you can call your own, where you pay rent, provides individuals with a sense of purpose,” said Stephani Ryan, director of LTSS Programs at BlueCare Tennessee.
Still, there hasn't been a national study that definitively shows MLTSS achieves both increased care quality and reduced costs, according to Musumeci at Kaiser. “The literature is still inconclusive,” she said.
Last year, the foundation launched a study of MLTSS programs in Ohio, Massachusetts and Virginia, but found insufficient evidence to draw conclusions.
Fragmentation of care for many of the beneficiaries who are dually eligible for Medicare and Medicaid also stands in the way of analyzing the effectiveness of moving to an MLTSS model. In some states, the managed-care plan only has control over long-term support benefits and not primary-care benefits under Medicare.
“When all you're responsible for is home care and long-term care, you're really doing care management with one hand tied behind your back,” said John Baackes, CEO of LA Care in California, which has created an MLTSS program specifically for dual-eligibles. “If we don't integrate MLTSS, it's never going to be 100% successful.”
Both the MLTSS program and the dual demonstration are part of a broader coordinated care initiative in California, which Gov. Jerry Brown has flagged as failing to save the state money. He's promising to end the experiment in 2018 if the trend doesn't turn around.
Plan managers are frustrated by expectations that MLTSS programs will show savings in just two or three years. “It can be challenging to manage expectations about the potential for immediate versus longer-term MLTSS beneficiary impact and cost savings,” said Friedman at Anthem, which runs MLTSS programs in eight states.
Policy makers need to understand that there are significant upfront costs for administrative and IT systems, Friedman said. In some cases, higher provider reimbursement rates are needed to build out a robust provider network that delivers high-quality services.
“Reducing overall cost and improving the health of program participants takes time, investment and a commitment to thoughtful program development,” he said.
Federal studies have also shown that MLTSS programs work best when the plan management company has control over a beneficiary's Medicare benefits as well as their Medicaid long-term care benefits. This past spring, HHS examined two programs in Minnesota that targeted Medicaid beneficiaries 65 and older in need of LTSS. Under one, the care of duals was fully integrated, while the other only allowed plans to have a say on a person's Medicaid benefits.
Enrollees in the coordinated effort were 48% less likely to have a hospital stay, and those that did wind up in the hospital had 26% fewer readmissions. They were also 16% less likely to have any assisted-living services.
MLTSS “works best when integrated with Medicare,” said Gretchen Ulbee, manager of special needs purchasing at the Minnesota Department of Human Services. “It's a lost opportunity if dual-eligible people have different coverage for their medical benefit.”
Dennis Heaphy, 55, a quadriplegic with MLTSS coverage under One Care, Massachusetts' financial alignment demonstration, said his life dramatically improved once his benefits were integrated. He received a higher-quality wheelchair from Commonwealth Care Alliance, his One Care plan, and a new lift was installed in his home to help his caretakers get him in and out of bed more efficiently.
“If my care became fractured again, I would become really concerned,” Heaphy said. “I don't want to be going in and out of the emergency room again.”