The objective of this paper is to develop a framework to guide practice and policy of managed care long term-services and support (MTLSS) for children with disability in New Hampshire (NH). The paper will evaluate the current state of practice in MCO for this vulnerable population, challenges with metrics development and implementation, impact on patient outcomes, and fiscal sustainability of the models. Stakeholder analysis, current scientific evidence, and experience of similar applicable models will guide recommendations for the project.
The Center for Medicare and Medicaid Innovation has awarded 16 States, a State Innovation Model (SIM) demonstration grants to developed models of care that improve care delivery and financing to contain cost, while improving quality. NH’s SIM project deserves a special consideration, as the State has joined a few who are focusing specifically on improving care for children with intellectual and developmental disability (IDD).
Persons with disability make up 15% of the Medicaid population and yet account for 42% of total Medicaid spending. This high expenditure is, however, devoid of expected health outcomes, and return on investment. Similar to national data, 16% of NH enrollees in Medicaid have disabilities, accounting for a disproportionate share of 64% of the State’s $1 billion healthcare expenditure. The State has prudently chosen to use its grants to achieve better care, better health, at reduced cost for its population in need of or at risk of needing Long-term services and support (LTSS) through managed care. The state has launched a statewide comprehensive managed care programs for acute and LTSS needs of persons with disabilities.
In this exploratory study, we conducted interviews with beneficiaries and families of disabled person both in NH and States with MLTSS experience, providers of acute and LTSS in NH, policies makers in NH, States with MLTSS experience(Kansas), and MCO in other States(KanCare, WI Family Care). The interviews were structured to capture 3 broad themes; would MCO achieve better care, would MCO achieve better health, and would MCO provide service at reduced cost. Stakeholders were also given the opportunity to provide recommendations as to how best to design MLTSS. These interviews were targeted to stakeholders with direct experience in this area, as well as those who agreed to participate through this short time period (February 2014 to April 2014). We do not assume that the observations made by stakeholders are representative of broader view around the country. This is clearly a limitation, but perhaps necessary one to capture more of what stakeholders in NH aspire to see in their managed care programs.
Limited data exist on managed care long-term services and support (MTLSS) for children with IDD; only 3 states have experience with MTLSS for children with IDD. Available data and state’s experience suggest that MCO have potential to achieve better health, better care, at a reduce cost (Triple Aim), but this is hard to say at this point. Beneficiaries are concerned that MCO will compromise utilization, and disrupt care in order to make profit. Providers, states officials, area agencies, and beneficiaries believe understanding culture of disability in NH is very important to better serve the IDD population. Stakeholders in NH are divided over whether MCO will be able to provider better care, better health at reduce cost. Beneficiaries are concerned that better care at “reduced cost” will translate to cuts in services or poor quality. Providers believe that the triple aim is achievable in MTLSS under the right conditions and supervision.
The importance of engaging all stakeholders (providers, beneficiaries, states, and MCO) at the front end is paramount to MLTSS planning, design, and implementation. The use of evidence based practices, continuous quality improvement, pursuit of relentless removal of waste that is not of value to the internal and external customer, appropriate supervision and capitated payments, all in context of patient centeredness should guide MTLSS. Quality metrics that achieve the triple aim for this population should be developed.
Karen Boudreau, MD, Chief Medical Officer, Boston Medical HealthNet, WellSense HealthPlan, New Hampshire