Pennsylvania MLTSS Initiative Shows Signs of Progress
Reprinted with AIS Health permission from the November 7, 2019, issue of RADAR on Medicare Advantage
As the Pennsylvania Dept. of Human Services prepares for the third and final phase of implementing its statewide managed long-term services and supports (MLTSS) program, Community HealthChoices (CHC), DHS is reporting “great success” with the rollout in the southwest and southeast regions of the program, which launched in January 2018 and January 2019, respectively. More than 210,000 older Pennsylvanians and adults with physical disabilities now “have an active voice when choosing how and where they receive their services and supports through CHC,” and more than half are receiving long-term care in the community, stated an Oct. 28 press release from DHS.
When fully implemented, more than 400,000 seniors and adults with physical disabilities across the state will have their physical and behavioral health services coordinated by a managed care organization, which is also responsible for connecting participants with home and community-based long-term services and supports (LTSS) and improving coordination with Medicare.
The program is for individuals aged 21 or older who are dually eligible for Medicare and Medicaid or who receive LTSS through Medicaid because they require the level of care provided by a nursing facility. Participants in a nursing facility may elect to stay in their facility as long as they need this level of care, and the CHC-MCOs must work with the state’s behavioral health MCOs to ensure that the needs of participants with behavioral health issues are addressed, regardless of where they reside. Ninety-four percent of the enrollees qualifying for CHC are dual eligible, estimated DHS.
Preliminary data from the southwest region shows that the percentage of individuals served in the community increased nearly 5% from 49.7% to 52.2% in CHC’s first year, said the press release. As of September 2019, that number increased to 54.8%, according to an updated figure shared with AIS Health.
Although DHS has not established specific benchmarks at this time, the recent increase “shows progress in the right direction” toward achieving the state’s goal of supporting long-term care in the community and the state “will continue to target initiatives that can improve this trend after the program is fully implemented,” says DHS spokesperson Erin James.
“I think it is definitely moving the needle in the right direction,” says Mary Kaschak, executive director of the National MLTSS Health Plan Association, referring to the 54.8% of individuals now receiving community-based long-term care. “I’d be concerned if there was a huge jump at the beginning of the program, because it takes time to get these programs up and running and to make sure that people are being transitioned appropriately back into the community.”
As with other state MLTSS programs, there is a 180-day continuity of care period during which the CHC-MCOs must assess their new enrollees and ensure that they have all the supports necessary to live in the home and community. But a lack of available and appropriate housing can be a barrier to those transitions, and DHS has established targeted housing as one of the service delivery innovations that CHC-MCOs must support, points out Kaschak.
There are three CHC-MCOs serving the program in each region, and they are operated by AmeriHealth Caritas, Centene Corp. and UPMC Health Plan. Although enrollment in the managed care program is mandatory, recipients have two chances to select their MCO before coverage begins.
Prior to the launches in the first two zones, AmeriHealth Caritas Pennsylvania Community HealthChoices and its sister CHC plan serving the southeast built relationships with local home and community-based services providers, nursing facilities, and other providers serving CHC participants. The two plans serve a combined 92,623 participants.
CHC-MCOs Build Close Provider Pacts
According to AmeriHealth Caritas spokesperson Joshua Brett, the plans held a total of 45 in-person training forums and 51 webinars to educate those providers on submitting claims, filing appeals and inquiries, and other aspects of working with an MCO, and with the two AmeriHealth Caritas plans specifically. Furthermore, they worked closely with the Office of Long Term Living and participated in its community meetings, including those for its MLTSS subcommittee as well as various advocacy and association CHC panel forums at conference and education sessions. AmeriHealth Caritas Pennsylvania Community HealthChoices is undertaking these same activities in preparation for CHC’s Phase 3 launch on Jan. 1, 2020.
A spokesperson for Centene’s Pennsylvania Health & Wellness (PHW) plan says it serves about 51,000 CHC enrollees and has transitioned 313 individuals from nursing facilities into the community so far. “That’s a 23% increase and a testament to PHW efforts to help participants live in community-based settings,” says PHW spokesperson Jay Pagni. Addressing social determinants of health and ensuring successful transitions to the community involves “strong involvement” with providers, advocacy, social service and other stakeholders, in addition to a “strong network of thousands of home health, personal assistance, adult day [care] and other community-based programs” across its regions to support members’ independent living.
UPMC Emphasizes Patient Choice
As part of the program rollout, UPMC “has been building upon the person-centered nature of CHC by emphasizing participant choice in the service delivery model,” says Brendan Harris, vice president of Community HealthChoices at UPMC Health Plan, which currently has 71,000 CHC members. “We are also building integrated supports to identify potential unmet home and community-based need — essentially using Medicare data to identify gaps in Medicaid services. With this work, each month an average of 94 participants start receiving services in the community by moving out of a nursing facility or being able to remain in their home even after a change in needs.”
UPMC CHC currently has 67% of LTSS participants in the community and only 33% in nursing facilities.
Pennsylvania is one of 25 states using one or more types of capitated managed care arrangements to coordinate LTSS, according to a recent Kaiser Family Foundation report (see infographic, this page). While MLTSS developments in every state are important to watch as other states consider ways to rebalance their LTSS spending, Pennsylvania is “particularly interesting because they rolled out the CHC program in their true urban areas first,” observes Kaschak. The final rollout is “small in terms of population but huge in terms of geography, so it must require different skill sets of the plans to be able to meet the needs of beneficiaries and find the providers and housing that may not be as prevalent in some of the more rural settings.”
According to James, one of the lessons the state has learned so far is to start communications and other activities earlier in the pre-launch process, including providing participants more time to select a plan. James says DHS also created an online training for participants to provide another channel for learning about the program changes. In addition, DHS began communicating with and training providers much earlier in the Phase 3 implementation process. And the state coordinated efforts with the three MCOs to host provider sessions and participant information sessions.
State, MCOs Build on Lessons Learned
Engaging providers earlier and offering more opportunities for training and testing “led to a smoother go-live in 2019,” adds Pagni. “For 2020 implementation, PHW has engaged providers since March of 2019, and has offered hundreds of trainings, dozens of provider educational town halls and scores of stakeholder presentations to enhance knowledge of the CHC program and to get providers prepared for the program.”
To address providers’ and patients’ fears about the changes associated with CHC, UPMC has focused on “communicating early and often,” says Harris. “While prior to the launch of the program in a particular region we cannot communicate directly with participants, we have been working with DHS and connecting with community organizations to ensure information and educational materials are shared. Working with community organizations has been a big asset as many times they are where participants get their information.”
James says DHS is looking forward to using the extensive quality- related data it’s received from the MCOs to “identify opportunities for service improvement and to measure quality in the program as a whole.”
Obtaining quality-related data in a new program like CHC is vital to its success, weighs in Jerry Vitti, founder and CEO of Healthcare Financial, Inc., a company that connects low-income, elderly and disabled populations with public benefit programs. “It’s important for states to gather the data to make data-driven decisions, because [while MLTSS] sounds good on paper, can you prove that a system like this helps people with issues like social determinants of health? Are people able to age in place? What is their quality of life? How are they doing in terms of behavioral health? And I would say that involves surveying members,” he suggests.
Are MCOs Targeting the Right Members?
Moving forward, it will also be important to make sure that efforts to connect enrollees with home and community-based services are targeting the members who need them most, adds Vitti. “If you hold a town hall type of meeting, you’re not going to get the sickest people, like the people with the transportation issues and other social determinants of health problems,” he says. “And that [initial 5% increase] doesn’t reveal whether that is the case or not….I think the data will help folks who run these programs, and the managed care organizations become accountable for data driven outcomes.”
Contact Brett at email@example.com, Harris via Ned Schano at firstname.lastname@example.org, James at email@example.com, Kaschak at firstname.lastname@example.org, Pagni at email@example.com or Vitti via Joe Reblando at firstname.lastname@example.org.
By Lauren Flynn Kelly