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Managed long-term care: Perspectives from a Managed Care Organization

Managed long-term care: Perspectives from a Managed Care Organization. Managed Long-Term Care:. October 24, 2011. What is Long-Term Services and Supports?.

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Managed long-term care: Perspectives from a Managed Care Organization

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  1. Managed long-term care: Perspectives from a Managed Care Organization Managed Long-Term Care: October 24, 2011

  2. What is Long-Term Services and Supports? • Long-Term Services and Supports (LTSS) refers to a broad range of services that support people who have limited ability to care for themselves due to physical, cognitive, or chronic health conditions. These conditions are expected to continue for an extended period of time (verses a short time such as after surgery) • Care needs arise because: • A condition present at birth. • Underlying health conditions common in older adults. • A condition or injury acquired during lifetime

  3. What is Long-Term Services and Supports? • A person needing Long-Term Care will require assistance with: • Activities of Daily Living (ADL’s) such as bathing, dressing, eating, transferring, walking and/or • Instrumental Activities of Daily Living (IADL’S) such as meal preparation, money management, housecleaning, grocery shopping, transportation.

  4. Individuals needing assistance get their care in: • Institutional or nursing facility placement • A community placement such as a group home or assisted living. • In their own home either living alone, living with family members

  5. The Challenge of State Budgets • For many states, Medicaid has become the largest state expense • Medicaid is equal or surpasses education, public safety and highways • High growth rates projected (even without health care reform adding to the rosters) National Association of State Budget Office Source: Urban Institute, 2007

  6. How do recipients feel about programs that support them at home or in community? • An AARP study shows 87% of people age 50 and older/ those who are physically disabled want to receive services in their own homes. • For Long-Term Care (LTC) Medicaid recipients prefer a plan that offers them choice of where they receive services.

  7. What do Managed Long-Term Care Models do? • A philosophy that members have a right to choose where they live, and it is our job to provide them with the support they need to be successful in that setting. • A network of trained providers that understand keeping members in the least-restricted environments, such as their homes, is the primary goal of the managed care organization. • Case coordinators with small case loads and who provide face-to-face visits with members that allow for early assessment of members who are declining and provide early and creative strategies that keep members from inappropriately entering institutional settings.

  8. So how does a Managed Care Organization (MCO) obtain a network of qualified providers that are committed to keep members in less restricted settings? • Contract standards • Rate negotiations • Case managers reporting • Quality providers/care concerns • Geographic/worker adequacy/ availability

  9. What kind of standards? • Staff qualification/ training • Length of time to services start • Supervisory oversight • Contingency workers – backup • Sometime worker reimbursement and benefits are requested and trended

  10. Median Hourly Wages for Personal and Home Care Aides and Home Health Aides 1999-2009 Source: http://www.hilltopinstitute.org/publications/RebalancingLTSS-ProgressToDateAndResearchAgendaForFuture-June2011.pdf figure 7

  11. Consumer directed/ Self directed • States may vary but usually three models: • Fiscal employer agent • Budget authority model • Agency model with worker choice • All models allow member or representative to have more control and decision making over their home care services

  12. Models: • “Fiscal Employer Agent” (also known as fiscal mediator). This where member or their designated representative is the employer of record (often with own FEIN-Federal tax number) and uses financial management service (FMS as designated agent to provide support for payroll, taxes, workers compensation etc. FMS may also assist with support tasks such as recruitment. A plan of care is developed based on needs and stats or MCO determines the number of hours per week of care.

  13. Models: • “Budget authority” (model also known cash and counseling as it was originally developed as part of a Robert Wood Johnson grant). In this model there is actually a capped monthly dollar amount where the consumer can purchase both goods and services. The dollar amount is authorized by the MCO and consumer can decide how to spend the money. The Financial Management Services (FMS) is agent pays the worker, buys the goods and ensures compliant spending.

  14. Models: • “Agency model with choice”. In this model there is an agency who pays the worker and is employer of record and the member assists in managing employee/worker by directing worker. The agency does all HR compliance and payroll plus hires, fires employee,) consumer may recommend)

  15. Questions Contact: Katherine Eskra Vice President, Aetna Medicaid Long-Term Care Kathy.Eskra@Aetna.com

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