2012 may prove to be as confusing and as dynamic as 2011 when it comes to long-term care changes. Clearly in 2011 there were planning efforts underway to implement various reform initiatives that passed the state legislature in 2008, 2009 and 2011; and the federal health care reform act of 2010. In other words, there is reform on top of reform on top of reform going on. … No wonder it is hard to keep up.

As the new year begins, I thought it would be helpful to provide an update on the various initiatives that are underway as well as an opinion on their impact. I apologize in advance for the lengthy list — it doesn’t even include all of the projects underway because that would be as long as a novel!

Long-term care financing reform: This is certainly not a new initiative — my bookshelf is full of the starts and stops on the ideas around personal responsibility and how to get consumers interested in saving for their long-term care needs. Whether the leader has been state agencies or legislators, editorial boards or private organizations such as the Citizens League, this issue has somehow not caught fire. 2012 will see another effort to light the fire with a Long-Term Care Aware campaign; a work plan should be available soon. This is a very important way to avoid the budget-busting that will otherwise occur in very short order.

Systems integration: The Department of Human Services (DHS) received federal funds for a three-year grant to work with the Board on Aging, Department of Health, and Area Agencies on Aging to focus on older adult connections — how to give consumers incentives to plan for service needs earlier, and to move the information upstream to places like the primary care clinics that are health care homes. As they think about how various seniors enter the system, we hope this initiative can get to the root of the problem — we have silos of services and payment that don’t communicate with each other. Health plans don’t even know when their enrollees have been hospitalized let alone what happens to them at discharge — this lack of coordination often results in unnecessary expenditures, whether public or private.

Quality measures/paying for performance: Yes, everyone wants to receive quality services. Not everyone wants to pay for them, of course. The state has a strong interest in developing quality measures for home- and community-based services (HCBS), but the data to do so is currently not that strong. Our experience has been that the most successful quality improvement initiatives — such as the Performance Incentive Payment Program (PIPP) — work with a carrot rather than a stick approach. Once the universal assessment (MN Choices) is fully implemented, there will be more data available on who is receiving what level of services. We hope the development of quality measures for HCBS is done cautiously, with external stakeholder input. What we don’t want to have happen is setting up incentives for “vanilla” services when one of the most positive aspects of our HCBS today is its variation and spectrum of choices.

Payment demonstrations (Health Care Homes and Multi Payer Advanced Primary Care Practice): Although the funding is going to the clinics only at this point in time, these demonstrations will only succeed if there is a connection between the clinic and the community long-term care services infrastructure.

Dual eligible demonstration: The state received two buckets of money — one to develop a data platform for connecting fee-for-service and health plan data; the other to develop a program for persons who are eligible for both Medicare and Medicaid in which the state could share some of the Medicare savings. There are many, many questions about how the latter could work in a state that has been using only managed care for this population for so long. One area where we could hope for a data review and an evaluation is in the financial obligations currently for health plans for the over-65 population. Right now their financial liability for nursing facility enrollees is limited to 180 days; yet the financial liability for the same population receiving waivered services is forever.

Return to the Community/Money Follows the Person: Both of these programs have the same goals: to move people out of “institutional” settings into the community. Return to the Community is for those with their own resources leaving nursing facilities (285 moved to date since April 2010); Money Follows the Person is for publicly funded folks; an estimated 2500 moved out over a five year period from nursing facilities and intermediate care facilities. While we agree with the state’s goal — serving the right people at the right level of service at the right time — we would like to see a cost-benefit analysis on these programs layered over all of the reductions to HCBS programs. We know people don’t select a nursing facility as their first choice of the place to receive the care and services they need; if there are other available, appropriate options in the community, those are the first choices. Over the past few budget deficits, however, the reductions to the HCBS infrastructure have been dramatic, so the concerns about access to appropriate levels of service remain.

Nursing facility level of care: Who can receive state-funded services either in waiver programs and/or nursing facilities will change either in July of this year or in January 2014, depending on how the federal government views our waiver. We have all sorts of concerns about the implications of these policy changes to the individuals we serve. You can read our comments on these changes here.

Standardization of processes: MN Choices, provider enrollment, ratesetting: Changes to all of the HCBS programs to standardize how individuals are assessed and enrolled, as well as how their services are paid for, are planned for a January 2013 implementation. We don’t really know what this will mean yet for our members, and are unclear about how the payers’ roles will be changing.

Accountable Care Organizations/total cost of care payments/bundled payments: all of the above initiatives are big changes, but won’t be nearly as dramatic as all of the private market changes that are underway, so hang on for the ride!

What are your thoughts on these initiatives? Post your comments to this blog online or email me at pcullen@careproviders.org. I want to know what you think!

Patti Cullen, CAE
952.851.2487
pcullen@careproviders.org

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