Quality in Managed Long-Term Services and Supports Programs

Executive Summary

Beth Jackson, Pat Rivard, Julie Seibert, Jason Rachel and Taylor Whitworth

Truven Health Analytics

November 2013

As of 2012, 16 states had managed long-term services and supports (MLTSS) programs for Medicaid beneficiaries. This is an exploratory study of how eight of these states implemented Medicaid MLTSS quality oversight in their programs. The eight state MLTSS systems studied are: Arizona Long-Term Care System (ALTCS); Michigan Managed Specialty Supports and Services; Minnesota Senior Care Plus and Minnesota Senior Health Options; North Carolina 1915(b)/(c) Medicaid Waiver for Mental Health/ Developmental Disabilities/Substance Abuse Services; Pennsylvania Adult Community Autism Program; Tennessee CHOICES in Long-Term Care; Texas STAR+PLUS Program; and Wisconsin's Family Care.

Under fee-for-service (FFS), the state's quality assurance focus is on monitoring long-term services and supports (LTSS) providers, including nursing facilities and intermediate care facilities for persons with intellectual disabilities as well as home care agencies and other home and community-based services (HCBS) providers, to ensure that the health and well-being of service recipients is safeguarded. When states contract with managed care organizations (MCOs) to assume responsibility for delivering all (or almost all) LTSS to MLTSS plan members, the state's quality assurance focus shifts to monitoring how well the MCOs meet their contractual obligations for meeting the needs of their enrolled members. Thus, in the MLTSS environment, states delegate the first line of quality oversight--the monitoring of service providers--to the MCOs.

The Centers for Medicare and Medicaid Services (CMS) has issued regulations requiring MLTSS MCOs to perform certain quality activities and through a combination of regulations and policy guidance, CMS has also specified what the federal Medicaid agency expects from states with respect to quality oversight of MCOs. However, states have considerable discretion as to how to meet these CMS requirements. This study describes similarities and differences in state approaches among eight states whose MLTSS programs had progressed beyond the initial start-up phase by the summer of 2013 when the case study research was conducted.

State Quality Assurance Oversight Infrastructure

The study found that Arizona (ALTCS) and Tennessee (TennCare) heavily leveraged the oversight infrastructure already in place to monitor medical services also provided by the participating MCOs. The other six states studied have established relatively free-look MLTSS oversight infrastructures. Four of the states (Minnesota, Tennessee, Texas, and Wisconsin) also delegate additional quality assurance and improvement activities to the external quality review organization (EQRO) beyond the EQRO activities that are federally-mandated.

States with free-standing MLTSS oversight infrastructures vary greatly in the magnitude of quality assurance staff employed relative to the number of Medicaid beneficiaries enrolled in MLTSS and relative to the number of participating MCOs that must be monitored. Wisconsin had the highest staffing ratios and North Carolina the lowest.

States also varied in their use of information technology to generate quality oversight reports electronically and provide automated tracking. The Texas and Tennessee MLTSS programs provided some examples of how information technology can enhance monitoring.

Monitoring and Improvement Activities

All MLTSS programs conduct routine audits; what varies greatly is their frequency and intensity of focus. Half the states conduct all audits annually. One state audits MCOs every other year and uses the off year to validate whether MCOs have implemented the corrective action plan based on the prior year's audits. Two states monitor MCOs on a three year cycle. One state conducts different types of audits with varying frequencies (annual, semi-annual, quarterly, and monthly).

There is considerable overlap in the performance measures states use. Many are the same as those developed for FFS 1915(c) waiver programs and include "process" as well as "outcome" measures. Typical process measures address: timeliness of screening, assessment, care planning and service delivery as well as critical incidence management and procedures for reporting and responding to grievances. Outcome measures specific to long-term care are few in number; health related outcome measures are more readily available and well defined. Where delivery of health and long-term care services is integrated, states are conceptually supportive of using health-related outcome measures to measure MCO performance. However, Medicaid officials also realize that if MCOs serve predominantly plan members who are dually Medicare/Medicaid eligible but the MCOs are not responsible for the Medicare-covered services, then the MCOs have little control over those providers and their accountability for health outcomes must be limited accordingly.

Six of the eight state MLTSS programs verify service receipt against what was authorized in the service plan; two states only verify service receipt against reimbursement. Only one state MLTSS program implements service verification on a real-time basis via an electronic visit verification (EVV) system that requires front-line home care workers to "clock-in." Failure to report in on schedule alerts provider agencies that they may need to deploy replacement workers. EVV also produces reports on missed and late visits by MCO, provider, and service type.

Seven states conduct mortality reviews on participants in HCBS waiver programs, but two only conduct such reviews on those considered especially vulnerable (e.g., services users with intellectual and developmental disabilities (IDD) or individuals with serious mental illness whose death was not anticipated).

All MLTSS programs require MCOs to obtain member feedback through the use of satisfaction or experience of care surveys. The survey instruments used and other means of obtaining member feedback vary greatly across the eight states. CMS expects states to involve MLTSS plan members in program evaluation and monitoring. However, only one state (Tennessee) requires each MCO to have advisory groups whose membership comprises at least 51% plan members.

All Medicaid managed care programs must have an ongoing series of performance improvement projects (PIPs) focused on clinical and non-clinical areas. The eight states varied greatly in the number of PIPs that MCOs are required to conduct related to LTSS (between one and three annually). In most states, MCOs individually develop and implement PIPs but in two states the MCOs work on PIPs collaboratively, which is especially helpful to providers that participate in more than one MCO's provider network.

The study identified multiple examples of states using monetary incentives, penalties, or withholds to support quality-related program expectations and goals.

Two states were in the process of developing MCO quality report cards.

Member Safeguards

Care coordination is the back-bone of MLTSS member safeguards. Some states mandate frequency of contact between care coordinators and members; others leave this to MCO discretion. Use of care coordination and requirements for frequency of use vary by LTSS populations (e.g., plan members with IDD receive care coordination routinely; whereas those with mental illness use it only sporadically because they rely more on mental health counselors and peers). Only four states specify care coordination ratios (i.e., numbers of care coordinators to plan members), which are recommended or developed collaboratively with the MCOs rather than mandated across the board. State approaches to monitoring MCO care coordination have evolved over time, in some cases becoming more prescriptive (e.g., requiring more frequent contacts with members, mandating the use of a statewide standardized assessment instrument).

CMS considers critical incident management highly important. At a minimum there must be provisions for mandatory reporting of abuse, neglect, or exploitation of LTSS service recipients. States typically delegate critical incident management to the MCOs but monitor their performance through audits and review of critical incident reports that MCOs must make to the states. States vary in their requirements for the frequency of critical incident reporting.

In most MLTSS programs studied, 24-hour back-up is a routine feature of the care delivery system through the use of MCO (or provider) round-the-clock hotlines or after-hours call-in systems to respond to members in need of assistance.

Balancing the Pros and Cons of Diversity and Flexibility Compared to Those of Standardization

Diversity is a traditional hallmark of the federal/state Medicaid program and flexibility--believed to encourage innovation--has been one of the core tenets of Medicaid MLTSS. Nevertheless, arguments can be made for more uniformity across states and MCOs in measuring the impact of MLTSS on beneficiaries' lives, particularly related to health outcomes and program participants' experience of quality of care and quality of life.