IPO Roadshow

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Myths and Realities of Integrated Long Term Care
Models
September 7, 2006
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What is an Integrated Long Term Care Model?

• Integrated models combine the medical services
  and community-based services into one program
• State health plan services
• Home and community-based waiver services
• Another type of integration occurs when the
  managed care organizations participating in a
  state initiative also offer a Medicare Special
  Needs Plan
• Can streamline access for Medicare and Medicaid
  for dual eligibles
• Helps facilitate services across the payer
  spectrum
• Integration facilitates the right service at the
  right time versus the limitation of service
  usually imposed by a waiver program or state
  benefit plan
• States frequently contract with Managed Care
  Organizations to achieve the integration
• The cornerstone of integration is
  person-centered, comprehensive, coordination of
  services across the spectrum of services available

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Services Covered by Integrated LTC Programs

• Medical Services usually include
• Hospital care
• Out-patient hospital services
• Physicians
• Other professional services
• Behavioral health services
• Lab and x-ray
• Home health
• PT, OT, ST
• Medical equipment and supplies
• Dialysis
• Prescriptions
• Other

• HCBS may include
• Emergency response system
• Homemaker/chore services
• Day Activity Health
• Home-delivered meals
• Assisted Living or other residential options
• Home modifications
• Respite care
• Home health, equipment and/or supplies not
  otherwise covered by Medicaid or Medicare
• Other

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Features of Integration

• Management through an ASO or risk arrangement
• Comprehensive Care Coordination
• Improved access to care
• Increased consumer focus
• Emphasis on home and community services

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Goals of Long Term Care Programs

• The goals of integrated Long Term Care programs
  include
• Streamlining and improving access to care
• Increasing consumer self-direction, choice and
  flexibility
• Enhancing alternatives to institutionalization
• Eliminating wait lists for services
• Improving health and quality outcomes
• Decreasing avoidable emergency room visits,
  hospital admissions, and nursing home placements
• Increasing the number of people served

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How are these Goals Achieved?

• Streamlining and improving access to care is
  achieved by making one organization accountable
  for
• Providing individuals with care coordination and
  education about all of the options available,
  helping clients to devise service plans, and
  managing all of the services necessary to each
  clients well-being regardless of payer or source
• Contracting with and managing all of the medical
  and community-based providers that clients may
  need
• Providing 24/7/365 customer service that includes
  a variety of professionals
• Increasing consumer self-direction and choice is
  achieved through
• Program design that provides flexibility in the
  care and services available
• Consumer-directed options that encourage hiring,
  firing, and managing ones own caregivers
• Enhancing alternatives to institutionalization
  are achieved through
• Care coordination that favors aging in place
  and community-based services
• Education of providers regarding new
  opportunities to expand their business models

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How are these Goals Achieved ? (continued)

• Eliminating wait lists for services
• Program design that allows clients to receive
  services throughout the spectrum of care
• Ability to control costs through an emphasis on
  lower-cost community-based alternatives to
  nursing home placements
• Improving health and quality outcomes is
  facilitated by
• Contract requirements
• Timely services
• Flexibility of services
• Decreasing avoidable emergency room visits,
  hospital admissions, and nursing home placements
• Flexible program design
• Comprehensive care coordination
• Increasing the number of people served
• Cost savings resulting from a decrease in
  avoidable episodes of care
• Decrease in waste resulting from better
  coordination of services

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Results

• Texas
• Arizona
• Florida

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Texas

• Texas has tested an integrated manage care model
  in the Houston area since 1998.
• It is a Medicaid managed care model that combines
  the behavioral, physical and community-based
  services for SSI recipients in Harris county.
• It is a mandatory program for those over age 19.
• Texas experienced the following results through
  its STARPLUS program
• 32 increase in clients use of in-home
  attendant care
• 38 increase in use of day activity health
  services
• 28 decrease in hospital admissions
• Overall costs for STARPLUS members decreased
  significantly with the increased used of home and
  community-based services in a comprehensive model

• From the Actuarial Assessment of Medicaid
  Managed Care Expansion Options, conducted by
  the Lewin Group on behalf of Texas Health and
  Human Services Commission, December, 2003

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Arizona

• Arizona has offered the Arizona Long Term Care
  System (ALTCS) model for nearly 20 years
• The model is mandatory for most Medicaid
  recipients that meet a nursing home level of care
  and combines physical, behavioral, and community
  based services in one program
• Arizona has experienced the following results
  from ALTCS
• 47 growth in home and community based services
  from 1997 through 2001
• More cost effective to maintain consumers in
  their own home
• Consumers were satisfied or very satisfied
  with their care 91 to 95 of the time

Arizona Community Baaed Services Settings
Report, May 2002
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Florida

• Florida offers a Long Term Care Diversion Waiver
  Program
• This program is voluntary for those eligible for
  both Medicare and Medicaid who meet the nursing
  home level of care and wish to remain in a
  community setting
• It integrates a variety of disparate community
  services with comprehensive care coordination
  however physical and behavioral health services
  are carved out of the model.
• Results The state estimated savings between
  10,000 and 14,000 per year by allowing
  community based services in lieu of nursing home
  placement.

Preliminary Evaluation of the Medicaid Waiver
Managed Long Term Care Diversion Programs Final
Report, Florida Department of Elder Affairs,
2001.
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Impact to Consumers

• Ability to be more fully integrated into the
  community
• Opportunity to live in the setting of choice
• Opportunity for consumer-direction
• Flexibility of services to meet individual needs
• Support through comprehensive care coordination
• Access to a full spectrum of services
• Increased customer satisfaction

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Impact to Providers

• Streamlined administrative processes
• One contact for all claims, authorizations, and
  care coordination services
• Billing processes may change
• Safety-net to support providers in managing
  clients with complex needs
• Care coordinator works actively with providers
• Arrange new services ordered, transportation to
  appointments
• Follows up on missed appointments, education
  needs
• Additional opportunities to serve clients
• Increased demand for home and community-based
  services
• Opportunities to expand into new geographies or
  business lines
• Faster response to requests for changes in level
  of care or service plan

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Impact to States

• Budget predictability
• Managed care reimbursement arrangements
• Decrease in emergency room visits, hospital
  admissions, and nursing home days
• Ability to cover more members within the current
  budget
• Improved Health Outcomes
• HEDIS measures
• Consumer satisfaction
• Provider satisfaction
• Other quality outcomes
• Ability to take advantage of new opportunities
• Money Follows the Person
• Deficit Reduction Act

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Quality Measures and Consumer Protections

• Quality Measures
• HEDIS health measures
• Disease-based health measures
• Access standards
• Operational standards
• Grievance and appeal standards

• Consumer Protections
• Choice of managed care options
• Ability to change plans
• Appeal and Grievance process
• Person-centered service-planning
• Quality measures

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Myths and Realities

• Realities
• Cost savings are achieved through decreasing
  avoidable episodes of care and increasing
  alternatives to institutionalization
• Integration streamlines access to services making
  it easier for consumers to get timely care and
  services
• Providers that understand the population and
  provide good service will see their market share
  grow
• Consumer protections leave individuals in the
  drivers seats with respect to providers and
  service plans

• Myths
• Cost savings are achieved through cuts in
  services to consumers or rates to providers
• Integration will add to the bureaucracy and make
  it more difficult to get services
• Traditional community providers will be pushed
  out of business
• Consumers will have to change providers, accept
  new services, have fewer choices