Quality in Managed Long-Term Services and Supports Programs

This report explores how several states have designed their quality monitoring and improvement programs for managed long-term services and supports (MLTSS). The authors focus on the early adopters of MLTSS as well as those programs that are presented considered "established". The findings demonstrate how states take somewhat different approaches to managed care organization oversight. [119 PDF pages]

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Acknowledgments

We are grateful to the states, managed care organizations and external quality review organizations who opened their doors to us and shared their particular methods, successes and challenges in managed long-term services and supports quality management. In particular, we acknowledge:

Arizona   Kim Elliott   Carol Sanders     Jami Snyder	Pennsylvania   Kevin Burwell   Elizabeth Kimball     Nina Wall
Michigan   Liz Knisely   Debra Ziegler	Tennessee   Michelle Morse-Jernigan     Patti Killingsworth
Minnesota   Sue Kvendru   Robert Lloyd   Pam Parker   Lisa Rotegard	Texas   Leslie Cisneros   Frank Genco   Michael Kaminer     Allison Moss   Lisa Niel   Paula Swenson
North Carolina   Deb Goda   Kathy Nichols   Adolph Simmons	Wisconsin   Reed Bonner   Monica Deignan     Jenifer Harrison

Acronyms

The following acronyms are mentioned in this report and/or appendices.

Executive Summary

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.

I. Introduction

A growing number of states have decided to expand their Medicaid managed care programs to encompass Long-Term Services and Supports (LTSS). From 2004 to 2012, the number of states with Medicaid managed LTSS (MLTSS) programs doubled from eight to 16, and ten more states are projected to implement MLTSS programs by 2014.¹ As states move their LTSS from a fee-for-service (FFS) environment to managed care, the nature of the state's quality oversight enterprise must ensure the compliance of the managed care organizations (MCOs) with whom they contract.

Under FFS, the state's quality focus is on monitoring providers (institutional providers, as well as those delivering home and community-based services (HCBS) and ensuring that the health and well-being of those served is safeguarded. The state's focus under managed care is monitoring the managed care entities to make certain that they meet contractual obligations for addressing the needs of their enrolled members. In the managed care environment, the first line of quality oversight is delegated to the MCO.

Among other obligations, the MCO must demonstrate to the state that:

• person-centered plans, based on comprehensive assessments, are developed with members;
• service plans meet members' needs and are responsive to their wishes for how services and supports will be delivered;
• services in the plan are actually delivered;
• services are coordinated (including health services);
• providers are responsive to members' changing needs and circumstances; and
• providers and the MCO address emerging member risk and critical events experienced by members.

In addition, Medicaid managed care regulations² require a further set of quality activities for the MCO not imposed in the FFS environment--Performance Improvement Projects (PIPs), an independent annual compliance review, as well as independent validationof the MCOs performance measures and PIP methodologies/results.

Through a combination of the CFR 438 Medicaid managed care regulations and recent guidance on the essential elements of MLTSS programs,³ the Centers for Medicare and Medicaid Services (CMS) provides states with expectations for quality oversight in MLTSS. CMS specifies what states must do. But, it is primarily at the states' discretion as to how they will implement CMS' requirements.

In this study, we explore how several states have designed their quality monitoring and improvement programs for MLTSS. We focus on the early adopters of MLTSS as well as those programs that are presently considered "established." As the findings of this report will demonstrate, states take somewhat different approaches to MCO oversight and we explore them in more detail below.

II. Study Approach

The nature of our study is exploratory with the goal to understand how a handful of states have implemented Medicaid MLTSS quality oversight in their programs. This is not an evaluative study where we seek to assess or rank the states on the quality in their programs, or to assess their compliance with federal regulation or guidance. Rather, it is to learn how they have crafted their quality strategies, what constitutes its components, and how their approaches to quality may have changed over time and why. The most appropriate methodology for such a study is the case study approach.

During the spring and summer months of 2013, staff from Truven Health Analytics conducted site visits to MLTS programs in Michigan, Wisconsin and Texas. During the visits we carried out semi-structured in-depth interviews with state and MCO⁴ Quality Assurance/Quality Improvement (QA/QI) staff. In two states (Texas, Wisconsin) we were also able to have discussions with the External Quality Review Organization (EQRO).

In addition, in the spring of 2012 prior to the initiation of this project, the Truven Health team had the opportunity to visit two other MLTSS programs in Arizona and Tennessee. We leveraged much of the information garnered in those visits for this study, augmented with follow-up phone interviews and e-mail exchanges during the course of the current project. Individuals on our team also had previous exposure to three other MLTSS programs in Minnesota, North Carolina and Pennsylvania which we have also drawn upon for this study; likewise, we conducted phone interviews with staff in these states to supplement existing information.

The MLTSS programs highlighted in this brief range from the earliest adopters in the late 1990s to programs initiated in 2009 and 2010. As shown in Exhibit 1, the populations served in these programs run the gamut from the aged and disabled to those with intellectual and developmental disabilities (IDD), autism and severe mental illness and substance use disorders (SUDs), with some programs integrating both health care and long-term care.

To guide the discussions with informants, Truven Health developed a discussion guide to elicit information on various quality topics covered by the study, including the state's infrastructure supporting quality activities, monitoring mechanisms, member safeguards, and changes in the state's quality management strategies over time. The discussion guide was used for the site visits, as well as for follow-up communications with MLTSS programs previously visited. It guided discussion as well with state staff from whom we wanted to acquire additional detail on certain topics and/or to elicit information on recent changes in their quality systems.

We also relied on an environmental scan developed by Truven Health of the quality provisions found in MLTSS MCO contracts. This scan includes quality-related contract requirements for all eight MLTSS programs which we focus upon in this study.⁵

The body of this report attempts to summarize the multiple components of the quality management systems in the eight MLTSS programs. These components can be organized into three broad categories:

• State infrastructure for monitoring quality;
• Monitoring and improvement activities; and
• Member safeguards.

At the end of the report, some additional quality-related topics that we pursued with our informants are presented.

The Appendices at the end of the report provides individual detailed summaries of the various components of the quality strategies in each of the eight MLTSS programs. The information residing there was gathered from our interviews, documents provided by the state, MCO or EQRO, as well as documents publicly available on state websites. We provide these more in-depth summaries of each state so that the reader has access to the rich detail about the structure of their quality management programs.

III. State Infrastructure for Quality Monitoring

CMS' recent guidance on the design of Medicaid MLTSS programs identifies the resources that a state must have for overseeing program quality. These include resources to:

• Conduct quality-focused audits;
• Evaluate MCO/provider quality reports;
• Trend data and identify areas for systems improvement;
• Validate corrective action plans;
• Develop and evaluate PIPs;
• Review/act on member feedback; and
• Ensure critical incidents/sentinel event are reported, investigated and addressed.

CMS's guidance also specifies that the resources that a state brings to bear (number and expertise of personnel, information technology assets) should be commensurate with the size and complexity of the program.

Among the study states we found that Arizona and Tennessee have heavily leveraged the oversight infrastructure used to monitor their managed health care plans--AHCCCS⁶ and TennCare, longstanding Medicaid managed care programs on the medical side. The other study states have established relatively free-standing MLTSS oversight infrastructures. Some of the states (Minnesota, Tennessee, Texas, and Wisconsin) also delegate additional quality assurance and improvement activities to the EQRO (beyond those EQRO activities that are federally-mandated).

While we do not have sufficient information to offer direct comparisons among the states on resources they allocate to quality, Exhibit 2 provides a glimpse into the magnitude of staffing each state employs relative to the numbers of members in the program and number of MCOs it monitors. It is difficult to compare the staffing complement in Arizona and Tennessee with the other states due to their draw on resources from their overarching Medicaid managed care program. Excluding these two states as well as Pennsylvania (an outlier in terms of number of members enrolled--only 130), a cursory comparison shows a range of quality staffing ratios. They range from one state quality staff per 2,905 MCO members in Wisconsin to one per 21,215 MCO members in North Carolina. Since the primary focus of state quality monitoring is the MCO, perhaps a more meaningful comparison is the number of quality staff per MCO. Here too we see ranges, from approximately 0.36 state full-time equivalents (FTEs) per MCO in North Carolina to 1.75 state FTEs per MCO in Wisconsin. Our comparisons in this instance are merely descriptive, but do raise questions for future inquiry about optimal staffing levels and whether there can be economies of scale with increased numbers of MCOs without sacrificing adequate monitoring.

The information technology capabilities of a state and how they support the quality enterprise are part of the infrastructure as well. A quality system is obviously much enhanced with the ability to generate reports electronically and provide automated tracking. Our case study programs provide some examples of how information technology enables enhanced monitoring. Texas's web-based portal allows the state, MCOs and the EQRO to view quality reports submitted by MCOs; they intend to offer access to providers in the future. Tennessee uses a customized off-the-shelf web-based tool to track receipt of all quality reports, corrective action plans and associated communications. All submissions from an MCO require action by a state employee to accept/reject the report/corrective action plan including the rationale for the disposition. This tool also documents all communications between the MCO and the state. In addition, Tennessee makes use of GeoAccess software to identify potential deficiencies in each MCO's provider network, including LTSS providers.

IV. Monitoring and Improvement Activities

All of the programs we examined rely on a variety of mechanisms to assess quality of care and MCO compliance with contract requirements for delivering services and supports. In this section we focus on audits, MCO reporting, verification of service receipt, mortality reviews, member feedback, how members participate in quality oversight, the EQRO's contributions to monitoring and improvement activities, the role of PIPs, how states use monetary incentives and penalties to reinforce quality objectives, and the use of MLTSS report cards.

A. Audits

All the MLTSS programs conduct routine audits of MCOs. What varies among them is the frequency and intensity of focus. Half of the programs conduct annual audits in-house (Pennsylvania, North Carolina, Texas, and Wisconsin), and two delegate this responsibility to the EQRO (Texas, Wisconsin).

Currently, Michigan conducts audits every other year on each MCO; in the off year they focus on validating that the MCO has implemented its corrective action plan from the previous year. Both Arizona and Minnesota audit the MCOs on a three-year cycle. Tennessee conducts different types of audits with varying frequencies:

• Annual: Fiscal Employer Agent (FEA) Audit; Area Agencies on Aging and Disability⁷ (AAAD) Audit; Money-Follows-the-Person⁸ (MFP) Audit, Provider Qualifications Audit.

• Semi-annual: Care Coordination Audit; Critical Incident Audit.

• Quarterly: New Member Audit; Referral Audit.

• Monthly: Network Adequacy Audit.

Minnesota's audit process begins with annual audits conducted internally by each MCO; the MCOs submit the results of their audits to the state. Eighteen months following receipt of each MCOs audit report the state then conducts a "look-behind" audit focused on the MCOs implementation of remediation activities in response to any issues or deficiencies that the MCO had identified.

One of Tennessee's additional care coordination auditing activities that sits outside the semi-annual audit bears mentioning. "Ride-alongs" have been instituted where state staff accompany the MCO care coordinator on member visits and assess the care coordinator's ability to meet contractual care coordination requirements. These "ride-alongs" occur six times per quarter per MCO, with the state sitting down with MCO management staff to debrief afterwards.

B. Managed Care Organization Performance Reporting

Information on MCO performance is not always articulated as "performance measures" per say, but may be found in reports that states require the MCO to submit. Several of the MLTSS programs are "combo" waivers (i.e., programs combining the 1915(c) authority for Medicaid HCBS waivers with the managed care authority of the 1915(a) or 1915(b)). With combo waivers CMS requires that the state collect, use and report performance measures demonstrating the state's adherence to the 1915(c) assurances, most of which are quality-related. States typically require that the data for the assurance-based performance measures, or the measures themselves, be reported by the MCOs. In recent years the "Terms and Conditions" of 1115 demonstration waivers, another regulatory vehicle used for MLTSS, have required performance measures for some of the 1915(c) assurances as well.

It is not surprising that many of the performance measures in MLTSS programs are similar to those found in the FFS 1915(c) programs. Even if CMS did not mandate "c-like" measures, one would still expect similar measures given the commonality of populations and expectations for good practice in assessment, person-centered planning, and safeguards for member health and welfare. Many of the process measures that the case study states report are related to timeliness of screening, assessment, care planning and service delivery as well as the extent to which defined processes for addressing critical incidents and grievances are followed.

In both FFS and MLTSS there is keen interest in the development and use of outcome measures for Medicaid LTSS programs.^{9, 10, 11, 12, 13, 14} Consensus about what constitutes "good" outcomes for individuals using LTSS is somewhat more elusive than in the health arena where treatment outcomes are more definitive. That said, the states in our study are collecting data on several outcome measures; some are population-specific and others are applied across populations.

EXHIBIT 3. Examples of Process Measures in Study States

Timeliness of screening/assessment/reassessment (based on state standard) Timeliness of service plan development (based on state standard) Timeliness of service initiation (based on state standard) Timeliness from FEA referral to receipt of consumer-directed services (based on state standard)   Timeliness of care coordinator face-to-face and telephonic contacts Care coordinator caseload & staffing ratio Percent of complaints received & resolved Late/missed visits by service type Percent of grievances received & resolved

Since there is considerable overlap in the measures used by the eight case study states, Exhibit 3 and Exhibit 4 present examples of some process and outcome measures, respectively, without identifying the states utilizing them. More details on performance measures employed by each state may be found in the Appendices at the end of this report.

EXHIBIT 4. Examples of Outcome Measures by Study States

Number of episodes of law enforcement involvement Number of psychiatric inpatient & emergency room hospitalizations Number of mental health crisis interventions Percent in competitive employment Percent living in a private residence alone, with spouse or non-relative Number of substantiated recipient rights complaints per 100 beneficiaries served   Increases in: Annual dental exams Diabetes management Annual gynecological exams Community tenure of persons transitioned from nursing homes Number of persons transitioned from nursing home to community Number of persons entering nursing home Potentially preventable readmissions Potentially preventable complications

The reader will notice that in Exhibit 4 some health-related outcomes are listed. Conceptually, states are supportive of including such measures, especially since one of the hallmarks of MLTSS is coordination of LTSS and medical care, with the intended effect being the achievement of better health outcomes. However at this juncture Medicaid agencies are somewhat reluctant to include health outcomes as performance measures until their plans are fully integrated with Medicare. While the MCOs may be expected to coordinate with Medicare providers that their members use, ultimately they do not have control over those providers. The states argue that neither they nor their MCOs should be held accountable for outcomes over which they do not exert control. This argument should abate as states begin participating in the CMS Duals Demonstrations.

C. Verification of Service Receipt

Verifying the delivery of home and community-based LTSS services is a critical component of managed care oversight due to the vulnerability of populations served. Late or missed visits, especially those that provide assistance in essential every day activities, place the member at potential risk of untoward outcomes. Moreover, managed care entities are required by federal regulation to monitor delivery of services by providers as well as take corrective action if service delivery is late or missed.¹⁵ In MLTSS, this requirement is closely connected to ensuring member safeguards, and important to allaying beneficiary and advocate fears that MCOs "skimp" on services in order to contain costs and maximize profit.

Five out of the eight programs verify service receipt against what was authorized in the service plan (Arizona, Michigan, Pennsylvania, Tennessee, Wisconsin); they compare whether members receive the services identified in their service plans. Two programs (Michigan, North Carolina) verify service receipt against reimbursement; the latter is a proxy approach because verification in this instance is not directly tied to the service plan. In seven out of the eight study states reviewed, states monitor service receipt retrospectively through reports submitted by the MCO.

Only in Tennessee is service verification done on a real-time basis. Tennessee utilizes an electronic visit verification (EVV) system where direct care providers clock-in and clock-out via phone from the member's home. The days and times that providers are expected to arrive are programmed into the system; if the worker does not clock-in within 15 minutes of the scheduled start time, an alert is sent to both the provider and the MCO. The MCO/provider is expected to deploy back-up workers and they, as well as the state, have the ability to track whether and when the replacement worker clocked in. The EVV system produces reports on missed and late visits by MCO, provider and service type.

The frequency of MCO reports on service verification varies from monthly in Arizona, and quarterly in Pennsylvania, to annually in North Carolina and Michigan.

Although its approach is still retrospective in nature, Arizona has implemented a "gap report" strategy that the MCO must submit monthly. What distinguishes Arizona from the other retrospective approaches is that their reporting requirements go beyond counts of missed visits and includes the reason for the service gap as well as actions taken at the individual level to address the missed visit.

While the retrospective validation approach is the most common, unless the MCO has a systematic mechanism for being alerted in a timely fashion when service delivery is late or missed, deployment of needed back-up help cannot be assured. On the other hand, while the EVV system in Tennessee is considered by many as a promising practice, it does have potential cost implications associated with up-front installation, as well as costs associated with staffing resources to monitor the EVV system for no-shows. For this approach to be most effective, it needs to be monitored (by providers and the MCO) in real-time so that when an alert is sent indicating a worker no-show, either the provider or MCO proactively contacts the member to assess the immediate need, and then deploys a back-up worker as necessary. In addition, the EVVs approach may also pose some challenges for verifying self-directed services. One of the features of self-direction is that it allows members to have flexibility about the day and time of day a service is delivered. As currently configured, EVV is driven by the date/time the worker is supposed to arrive and if a member changes this without formally requesting a change, then a worker no-show alert will be triggered. Moving forward it will be instructive to follow how Tennessee addresses this seeming constraint in the EVV system.

D. Mortality Reviews

In 2008, the U.S. Government Accountability Office (GAO) recommended that CMS encourage states to conduct mortality reviews in 1915(c) HCBS waivers.¹⁶ The mortality review process typically involves screening a death to ascertain whether it meets a pre-determined criteria for an in-depth review, investigation by a mortality review committee of circumstances that led to the death, a systems-level review to examine any commonalities across deaths to identify and recommend changes to reduce future risk of death.

The GAO was silent on the advisability of mortality reviews for 1915(c) waivers serving other populations and for MLTSS programs. However, good practice in community-based LTSS suggests that mortality reviews are an important oversight in LTSS program.¹⁷ Among the programs reviewed, we found evidence that seven conduct mortality reviews. Six delegate this responsibility to the MCO. The Michigan program which enrolls members with severe mental illness and IDD requires investigation of unexpected deaths only. Arizona requires MCOs to conduct mortality review for deaths among members with IDD only. The Tennessee Choices program, serving the Aged/Disabled population, does not require mortality reviews.

E. Member Feedback

CMS' recent MLTSS guidance calls for states and/or MCOs to measure members' experience of care and quality of life. All of the programs reviewed field either satisfaction or experience of care surveys, with most administering them on an annual basis. In some instances, the surveys are conducted by the state, whereas others are completed by the MCO. There are a few examples of these surveys being administered by a contractor (EQRO, AAAD,¹⁸ FEA¹⁹). In a few cases, there is a dual-survey approach where both the state and either the MCO or another contractor conduct them. In Michigan, separate surveys are conducted with members having mental illness and IDD. A few states use externally tested instruments (Mental Health Statistics Improvement Program [MHSIP], Core Indicators, Participant Experience Survey (PES), HCBS Experience of Care Survey) while others rely on state or MCO-developed instruments. In addition to surveying members, two of the programs conduct focus groups (Pennsylvania) or listening sessions (Wisconsin) with members.

F. Member Oversight

"Stakeholder engagement", inclusive of program oversight, is considered a key element in CMS' guidance document. Moving forward, CMS expects states to involve stakeholders, including members, in program evaluation and monitoring. CMS also expects states to require MCOs to convene member advisory committees to provide feedback on MCO MLTSS operations. We were therefore interested in learning how the established MLTSS programs engage members in monitoring and broader program oversight.

In Michigan, members sit on a quality committee and in North Carolina and Texas they have seats on advisory committees. Five programs require advisory committees or state staff to elicit input from members as part of an MCO's annual review or periodically through member focus groups. Three programs require MCOs to engage members either by having them serve on the MCOs' governing board (Wisconsin), or by having seats on the MCOs' Advisory and/or Quality Committees (Pennsylvania, Tennessee). Minnesota requires that each MCO have a Member Advisory Committee and that it meet regularly. Tennessee is unique in that it requires each MCO to have at least 51% of the seats on their Advisory Group be comprised of members or their authorized representatives.

G. External Quality Review Organization Responsibilities

Our interest in the EQRO pertains to activities they perform above and beyond those required under the Medicaid managed care regulations (compliance review, validation of encounter data, performance measures and PIPs). In particular, we were focused on additional quality management activities for which states employ EQROs in their MLTSS programs.

Four of the study states maintain a more traditional relationship with their EQRO (Arizona, Michigan, Minnesota, and Pennsylvania). But in Wisconsin, the EQRO takes on the added task of conducting the care management review in the MCOs. The EQRO assumes multiple additional tasks in Tennessee; rather than just validating PIPs they are involved in assisting the MCOs with PIP implementation, as well as responsibilities for training the MCOs and state staff on quality-related issues. The Tennessee EQRO also reviews all MCO corrective action plans from its annual compliance review and conducts a legislatively-mandated network adequacy review. The EQRO's scope of work in Texas includes focused studies, an annual satisfaction survey of members, validating encounter data as well as developing data for the program's performance dashboard and planned MCO report cards.

H. Long-Term Services and Supports Performance Improvement Projects

All Medicaid managed care programs must have an ongoing series of PIPs focused on clinical and non-clinical areas.²⁰ In this inquiry, our interest was to discover the types of PIPs MLTSS programs conduct and if they have particular relevance to MLTSS services and/or populations--in essence whether the programs require their MCOs to engage in LTSS-specific PIPs.

PIPs often span more than one year as they require time for design and implementation, as well as time to review results and draw conclusions about the PIP's impact. Two of the study programs require the MCOs to conduct at least one LTSS PIP (Pennsylvania, Wisconsin); two states mandate two LTSS PIPs (Michigan, Tennessee); and two programs require three LTSS PIPs (North Carolina, Texas). In some states, some PIPs are dictated by the state, where in others they are at the discretion of the MCO. In some cases, the state may periodically mandate a specific PIP (e.g., in 2012 Tennessee required a PIP on rebalancing). In Texas, the EQRO establishes two of the three PIPs with the third at the MCO's discretion. Examples of LTSS PIPs in addition to Tennessee's rebalancing PIP include improvement initiatives on:

• Increased use of adult day care;
• Increased integration of behavior and physical health;
• Increases in depression screenings;
• Reduction in preventable hospitalizations;
• Increases in diabetic care; and
• Reduction in nursing facility rates.

Another approach that surfaced is an initiative in Texas and Minnesota where MCOs work together to develop collaborative PIPs. The advantages of this approach is that the MCOs are not working at odds with each other, and it is especially helpful for providers who may be involved in implementing PIPs who work for more than one MCO.

I. Quality-Related Financial Incentives, Penalties and Withholds

States have opportunity in designing their payment structures to reward MCOs for quality care/outcomes and to dis-incentivize them for performance below acceptable thresholds. In our interviews with states as well as in reviewing MCO contracts and other supporting information on state websites, we identified multiple examples of states using monetary incentives, penalties or withholdsto support quality-related program expectations and goals.

Five programs offer quality-related incentives (Michigan, Minnesota, Tennessee, Texas, and Wisconsin), two issue monetary penalties (Minnesota, Tennessee) and four impose quality-related withholds (Minnesota, Pennsylvania, Tennessee, Texas). Monetary incentives are offered for:

• Transitioning members from institutional settings to community (Wisconsin, Tennessee).

• Increasing number of members with self-determination arrangements (Michigan).

• Improvement in number of consumers engaged in meaningful employment (Michigan).

• Improvement in number of consumers in private residence (Michigan).

• Improvement in number of consumers discharged from detoxification unit and seen for follow-up within seven days (Michigan).

• Superior clinical quality, service delivery, access to care and/or member satisfaction (Texas).

• Reductions in inpatient hospital costs (Texas).

• Optimal chronic disease care (limited to diabetes care, coronary/vascular disease care) (Minnesota).

In Michigan penalties can be levied for patterns of non-compliance, poor performance on a performance indicator standard, substantial inappropriate denial of services, and substantial or repeated health and safety violations. Tennessee is a strong advocate for assessing liquidated damages and its MCO contracts include detailed tables of amounts per infraction for "transgressions or omissions" ranging from threats to the smooth and efficient operation of the program to actions/inactions that result in threat to the member. Penalties can range from $100 per day to $10,000 per month depending on the breach.

Withholds of MCO payments are a tool used by Pennsylvania, Tennessee, and Texas to encourage delivery of good quality of care and services. Minnesota uses withholds for promoting MCO compliance with completing and submitting care plan audits and health risk screenings/assessments.

J. Report Cards

Two states were in the process of developing report cards at the time the study was being conducted. In Texas, the EQRO was assisting the state to finalize a legislatively-mandated MCO report card which will eventually be published on the state's website.

Tennessee was developing their report card from a combination of data from required MCO reports and audit results. At the time of the study, the report card was being used internally by state monitoring staff in MCO oversight. In the future the state expects to integrate the MCO performance data into the larger report card structure for the entire Medicaid managed care program (TennCare).

C. Verification of Service Receipt

Verifying the delivery of home and community-based LTSS services is a critical component of managed care oversight due to the vulnerability of populations served. Late or missed visits, especially those that provide assistance in essential every day activities, place the member at potential risk of untoward outcomes. Moreover, managed care entities are required by federal regulation to monitor delivery of services by providers as well as take corrective action if service delivery is late or missed.¹⁵ In MLTSS, this requirement is closely connected to ensuring member safeguards, and important to allaying beneficiary and advocate fears that MCOs "skimp" on services in order to contain costs and maximize profit.

Five out of the eight programs verify service receipt against what was authorized in the service plan (Arizona, Michigan, Pennsylvania, Tennessee, Wisconsin); they compare whether members receive the services identified in their service plans. Two programs (Michigan, North Carolina) verify service receipt against reimbursement; the latter is a proxy approach because verification in this instance is not directly tied to the service plan. In seven out of the eight study states reviewed, states monitor service receipt retrospectively through reports submitted by the MCO.

Only in Tennessee is service verification done on a real-time basis. Tennessee utilizes an electronic visit verification (EVV) system where direct care providers clock-in and clock-out via phone from the member's home. The days and times that providers are expected to arrive are programmed into the system; if the worker does not clock-in within 15 minutes of the scheduled start time, an alert is sent to both the provider and the MCO. The MCO/provider is expected to deploy back-up workers and they, as well as the state, have the ability to track whether and when the replacement worker clocked in. The EVV system produces reports on missed and late visits by MCO, provider and service type.

The frequency of MCO reports on service verification varies from monthly in Arizona, and quarterly in Pennsylvania, to annually in North Carolina and Michigan.

Although its approach is still retrospective in nature, Arizona has implemented a "gap report" strategy that the MCO must submit monthly. What distinguishes Arizona from the other retrospective approaches is that their reporting requirements go beyond counts of missed visits and includes the reason for the service gap as well as actions taken at the individual level to address the missed visit.

While the retrospective validation approach is the most common, unless the MCO has a systematic mechanism for being alerted in a timely fashion when service delivery is late or missed, deployment of needed back-up help cannot be assured. On the other hand, while the EVV system in Tennessee is considered by many as a promising practice, it does have potential cost implications associated with up-front installation, as well as costs associated with staffing resources to monitor the EVV system for no-shows. For this approach to be most effective, it needs to be monitored (by providers and the MCO) in real-time so that when an alert is sent indicating a worker no-show, either the provider or MCO proactively contacts the member to assess the immediate need, and then deploys a back-up worker as necessary. In addition, the EVVs approach may also pose some challenges for verifying self-directed services. One of the features of self-direction is that it allows members to have flexibility about the day and time of day a service is delivered. As currently configured, EVV is driven by the date/time the worker is supposed to arrive and if a member changes this without formally requesting a change, then a worker no-show alert will be triggered. Moving forward it will be instructive to follow how Tennessee addresses this seeming constraint in the EVV system.

D. Mortality Reviews

In 2008, the U.S. Government Accountability Office (GAO) recommended that CMS encourage states to conduct mortality reviews in 1915(c) HCBS waivers.¹⁶ The mortality review process typically involves screening a death to ascertain whether it meets a pre-determined criteria for an in-depth review, investigation by a mortality review committee of circumstances that led to the death, a systems-level review to examine any commonalities across deaths to identify and recommend changes to reduce future risk of death.

The GAO was silent on the advisability of mortality reviews for 1915(c) waivers serving other populations and for MLTSS programs. However, good practice in community-based LTSS suggests that mortality reviews are an important oversight in LTSS program.¹⁷ Among the programs reviewed, we found evidence that seven conduct mortality reviews. Six delegate this responsibility to the MCO. The Michigan program which enrolls members with severe mental illness and IDD requires investigation of unexpected deaths only. Arizona requires MCOs to conduct mortality review for deaths among members with IDD only. The Tennessee Choices program, serving the Aged/Disabled population, does not require mortality reviews.

E. Member Feedback

CMS' recent MLTSS guidance calls for states and/or MCOs to measure members' experience of care and quality of life. All of the programs reviewed field either satisfaction or experience of care surveys, with most administering them on an annual basis. In some instances, the surveys are conducted by the state, whereas others are completed by the MCO. There are a few examples of these surveys being administered by a contractor (EQRO, AAAD,¹⁸ FEA¹⁹). In a few cases, there is a dual-survey approach where both the state and either the MCO or another contractor conduct them. In Michigan, separate surveys are conducted with members having mental illness and IDD. A few states use externally tested instruments (Mental Health Statistics Improvement Program [MHSIP], Core Indicators, Participant Experience Survey (PES), HCBS Experience of Care Survey) while others rely on state or MCO-developed instruments. In addition to surveying members, two of the programs conduct focus groups (Pennsylvania) or listening sessions (Wisconsin) with members.

F. Member Oversight

"Stakeholder engagement", inclusive of program oversight, is considered a key element in CMS' guidance document. Moving forward, CMS expects states to involve stakeholders, including members, in program evaluation and monitoring. CMS also expects states to require MCOs to convene member advisory committees to provide feedback on MCO MLTSS operations. We were therefore interested in learning how the established MLTSS programs engage members in monitoring and broader program oversight.

In Michigan, members sit on a quality committee and in North Carolina and Texas they have seats on advisory committees. Five programs require advisory committees or state staff to elicit input from members as part of an MCO's annual review or periodically through member focus groups. Three programs require MCOs to engage members either by having them serve on the MCOs' governing board (Wisconsin), or by having seats on the MCOs' Advisory and/or Quality Committees (Pennsylvania, Tennessee). Minnesota requires that each MCO have a Member Advisory Committee and that it meet regularly. Tennessee is unique in that it requires each MCO to have at least 51% of the seats on their Advisory Group be comprised of members or their authorized representatives.

G. External Quality Review Organization Responsibilities

Our interest in the EQRO pertains to activities they perform above and beyond those required under the Medicaid managed care regulations (compliance review, validation of encounter data, performance measures and PIPs). In particular, we were focused on additional quality management activities for which states employ EQROs in their MLTSS programs.

Four of the study states maintain a more traditional relationship with their EQRO (Arizona, Michigan, Minnesota, and Pennsylvania). But in Wisconsin, the EQRO takes on the added task of conducting the care management review in the MCOs. The EQRO assumes multiple additional tasks in Tennessee; rather than just validating PIPs they are involved in assisting the MCOs with PIP implementation, as well as responsibilities for training the MCOs and state staff on quality-related issues. The Tennessee EQRO also reviews all MCO corrective action plans from its annual compliance review and conducts a legislatively-mandated network adequacy review. The EQRO's scope of work in Texas includes focused studies, an annual satisfaction survey of members, validating encounter data as well as developing data for the program's performance dashboard and planned MCO report cards.

H. Long-Term Services and Supports Performance Improvement Projects

All Medicaid managed care programs must have an ongoing series of PIPs focused on clinical and non-clinical areas.²⁰ In this inquiry, our interest was to discover the types of PIPs MLTSS programs conduct and if they have particular relevance to MLTSS services and/or populations--in essence whether the programs require their MCOs to engage in LTSS-specific PIPs.

PIPs often span more than one year as they require time for design and implementation, as well as time to review results and draw conclusions about the PIP's impact. Two of the study programs require the MCOs to conduct at least one LTSS PIP (Pennsylvania, Wisconsin); two states mandate two LTSS PIPs (Michigan, Tennessee); and two programs require three LTSS PIPs (North Carolina, Texas). In some states, some PIPs are dictated by the state, where in others they are at the discretion of the MCO. In some cases, the state may periodically mandate a specific PIP (e.g., in 2012 Tennessee required a PIP on rebalancing). In Texas, the EQRO establishes two of the three PIPs with the third at the MCO's discretion. Examples of LTSS PIPs in addition to Tennessee's rebalancing PIP include improvement initiatives on:

• Increased use of adult day care;
• Increased integration of behavior and physical health;
• Increases in depression screenings;
• Reduction in preventable hospitalizations;
• Increases in diabetic care; and
• Reduction in nursing facility rates.

Another approach that surfaced is an initiative in Texas and Minnesota where MCOs work together to develop collaborative PIPs. The advantages of this approach is that the MCOs are not working at odds with each other, and it is especially helpful for providers who may be involved in implementing PIPs who work for more than one MCO.

I. Quality-Related Financial Incentives, Penalties and Withholds

States have opportunity in designing their payment structures to reward MCOs for quality care/outcomes and to dis-incentivize them for performance below acceptable thresholds. In our interviews with states as well as in reviewing MCO contracts and other supporting information on state websites, we identified multiple examples of states using monetary incentives, penalties or withholdsto support quality-related program expectations and goals.

Five programs offer quality-related incentives (Michigan, Minnesota, Tennessee, Texas, and Wisconsin), two issue monetary penalties (Minnesota, Tennessee) and four impose quality-related withholds (Minnesota, Pennsylvania, Tennessee, Texas). Monetary incentives are offered for:

• Transitioning members from institutional settings to community (Wisconsin, Tennessee).

• Increasing number of members with self-determination arrangements (Michigan).

• Improvement in number of consumers engaged in meaningful employment (Michigan).

• Improvement in number of consumers in private residence (Michigan).

• Improvement in number of consumers discharged from detoxification unit and seen for follow-up within seven days (Michigan).

• Superior clinical quality, service delivery, access to care and/or member satisfaction (Texas).

• Reductions in inpatient hospital costs (Texas).

• Optimal chronic disease care (limited to diabetes care, coronary/vascular disease care) (Minnesota).

In Michigan penalties can be levied for patterns of non-compliance, poor performance on a performance indicator standard, substantial inappropriate denial of services, and substantial or repeated health and safety violations. Tennessee is a strong advocate for assessing liquidated damages and its MCO contracts include detailed tables of amounts per infraction for "transgressions or omissions" ranging from threats to the smooth and efficient operation of the program to actions/inactions that result in threat to the member. Penalties can range from $100 per day to $10,000 per month depending on the breach.

Withholds of MCO payments are a tool used by Pennsylvania, Tennessee, and Texas to encourage delivery of good quality of care and services. Minnesota uses withholds for promoting MCO compliance with completing and submitting care plan audits and health risk screenings/assessments.

J. Report Cards

Two states were in the process of developing report cards at the time the study was being conducted. In Texas, the EQRO was assisting the state to finalize a legislatively-mandated MCO report card which will eventually be published on the state's website.

Tennessee was developing their report card from a combination of data from required MCO reports and audit results. At the time of the study, the report card was being used internally by state monitoring staff in MCO oversight. In the future the state expects to integrate the MCO performance data into the larger report card structure for the entire Medicaid managed care program (TennCare).

V. Member Safeguards

Member safeguards are a critical component of the design of any MLTSS program, and serve to protect the health, safety and welfare of persons served, typically individuals with cognitive, emotional and/or physical vulnerabilities.

A. Care Coordination

Care coordination is the back-bone of member safeguards. Care coordinators are the system's eyes and ears for ensuring the well-being of members. They help the individual devise a service/support plan that is intended to meet their unmet needs, minimize risk, maintain health/function, and provide quality of life. Following the service initiation, it is then incumbent on the care coordinator to monitor the member's receipt of services as well as any circumstances that signal a need for a change in the plan (e.g., health change, mental health crises, change in the informal support system, increased risk taking, etc.) thereby minimizing the member's exposure to risk and consequent threats to health, functioning or quality of life. Assisting the person with coordination of acute care and behavioral health needs also falls to the care coordinator, as well as assistance with transitions related to hospitalizations and institutional care.

i. Required Contacts with Members

Given the importance of care coordinator contacts with members, we included this element in our case studies. Among the study states, contract frequency ranges from discretion of the MCO, to some combination of MCO discretion and required frequency of contracts, to prescribed frequency. A breakdown of these approaches is provided in Exhibit 6.

Both Michigan and North Carolina serve persons with mental illness and SUDs, as well as the IDD populations. North Carolina's newer program is modeled on Michigan's longstanding program and thus it is not surprising that their requirements are somewhat similar (no requirement and determined by need, respectively). In our interviews with state officials they noted that the care coordination needs for the mentally ill population is very different than for IDD members. The IDD population uses care coordination on a routine basis whereas members with mental illness use it only sporadically since their main support comes from mental health counselors and peers. When the mental illness population does utilize care coordination, it is typically for assistance with housing or other social services.

Wisconsin requires quarterly contacts for the first six months, and subsequently leaves it to the MCO to determine how frequently a given member needs to be contacted (but with a minimum of a yearly contact). By six months it is assumed that a relationship has been established between the member and the care coordinator and that the care coordinator can best determine how often contact is needed.

There is also variability around whether contacts must be conducted face-to-face, on the phone, or even by mail. For example, Texas allows any type of contact, whereas most of the other programs specify in-person. The exception is Tennessee which allows some contacts by phone as noted above.

ii. Care Coordination Ratios

Four out of the eight study states do not specify any care coordination ratios. Only Arizona has absolute maximum ratios and uses a weighting scheme that accounts for the case-mix of the care coordinator's caseload (i.e., HCBS, nursing facility, assisted living).

The MCOs in Minnesota must submit their ratio policies to the state for review. If the MCOs ratios in Wisconsin vary from state norms, then the state may ask the MCO to justify its ratios. Tennessee recommends maximum ratios, but does not mandate them. However, if the MCO is found out-of-compliance with any care coordination contractual requirements and its ratios exceed that which the state has recommended, it is assessed liquidated damages.

iii. Evolution of Care Coordination

It is always instructive to learn from states how their programs develop and change over time. Arizona told us that they discovered that when a member moved from one MCO to another, care plans and service authorizations often changed as a result of the MCOs using their own assessment instruments. For reasons of equity, the state decided to mandate a uniform assessment which has resulted in more consistency across the MCOs in service planning and authorizations. Arizona's move to a uniform assessment is consistent with emerging consensus that a uniform assessment instrument is best practice and something CMS is now requiring for states participating in the Balancing Incentives Program.²¹

At the time of our interview, Texas was on the cusp of becoming more prescriptive in its requirements for care coordinator contacts with members due to a stakeholder feedback and a resulting legislative mandate. They were moving from two member contacts per year where it was the discretion of the MCO how to make the contact (in-person, phone, mail) to a system based on the member's acuity and risk levels with prescribed modes of contact for each level. For example, those at highest risk will receive two face-to-face visits per year by an assigned (consistent) care coordinator while those at lowest risk will receive two phone contacts per year by any care coordinator.

During interviews we also inquired about any instances of tension between care coordinators and MCO staff responsible for authorizing services. Both state and MCO staff in Michigan mentioned that care coordinators had been frustrated at an earlier point in time about service denials by the MCO's utilization management. Apparently the cause of many denials was inadequate documentation by care coordinators, which was subsequently addressed, and tension between the two had dissipated. In the discussion of this topic, both state officials and the MCO wanted it understood that in Michigan the MCOs (technically PIHPs), are non-profit entities (Community Mental Health Service Programs) and as such there was not profit motive or incentive to limit member utilization. Our discussions with North Carolina reported little tension between care coordinators and those authorizing services. The North Carolina program also serves members through non-profit MCOs, and they too mentioned that there was no financial motive for restricting services.

While Pennsylvania officials did not voice any current concern about care coordinator conflicts with the MCOs utilization management, they did mention that when the program was being developed that consumers and advocates were anxious that services would be reduced under managed care. The state tried to reframe the issue by focusing on the care coordinator's role to increase member independence with care coordinator support. Members' and advocates' initial concern have not resurfaced since program implementation.

B. Critical Incident Review and Investigation

In recent years, CMS has placed substantial emphasis on the importance of critical incident management processes in the 1915(c) HCBS waiver programs. With CMS' MLTSS guidance, this expectation now extends to MLTSS programs.

At a minimum, it is expected that there are provisions for the mandatory reporting of abuse, neglect or exploitation involving program participants. Robust critical incident management systems have structures and process in place for the receipt of reports and for their investigation, as well as protocols for urgent response when a member's health or safety is in immediate jeopardy.

The MLTSS study programs substantially delegate this responsibility to the MCOs. The states then monitor the MCO's management of critical incidents when they conduct audits and/or review MCO reports. Some states require the MCO to report certain events immediately or within 24 hours of their occurrence. For example, Wisconsin requires the MCO to report "egregious" incidents immediately. Michigan requires reporting certain deaths within 24 hours (i.e., those that occur as a result of suspected provider action/inaction and those that are the subject of a recipient's rights, licensing or police investigation). In Tennessee, any death or incident that could significantly impact the health or safety of a member must be reported to the state within 24 hours.

States vary in their approaches to overseeing the MCO's management of critical incidents. Several states require quarterly critical incident reports from the MCO (Tennessee, Texas, Wisconsin). Michigan requires reports to be submitted within 60 days following the end of the month when the incident occurred. In addition to requiring quarterly reports from MCOs, Tennessee also conducts semi-annual audits of the MCO's handling of critical incidents.

Only one program--Pennsylvania--has a centralized web-based system that serves as the repository for critical incident reports that must be submitted by the MCO within 24 hours. This system allows both the MCOs and the state to monitor how critical incidents are managed and resolved.

C. 24-Hour Back-up

Twenty-four hour back-up can refer to having an informal back-up plan in the event that a direct care worker does not show, as well as to the existence of a formal systems-level back-up when the informal back-up plan fails. This may include on-call care coordinators and/or providers.

Historically states resisted a formal 24-hour back-up provision in participant-directed services when it was first proposed for the Independence Plus designation for 1915(c) waiver programs (subsequently rescinded). And more recently, some states have been challenged to fully comply with the systems-level 24-hour back-up requirement in the MFP demonstrations. The argument against requiring 24-hour back-up in the FFS environment has been the cost associated with on-call personnel. Yet, in most MLTSS programs we investigated, 24-hour back-up is a routine feature of the care delivery system with MCO (or provider) round-the-clock hotlines or after-hours call-in systems in place to respond to members in need of assistance.

D. Ombudsman

Technically an ombudsman is a neutral party that can advocate for the member in disputes with the MCO or state regarding their services and supports. Three of the examined programs offered independent state ombudsman programs either devoted exclusively to the MLTSS program (Wisconsin) or to Medicaid managed care more generally (Texas, Minnesota).

Four programs (Michigan, Tennessee, Texas, and Wisconsin) also require that the MCO offer ombudsman-like services to their members, but these services are clearly not independent as these services are provided by MCO staff. The MCOs refer to these positions as variably as "member advocates", "member rights specialists" or "customer services".

In addition to advocacy, responsibilities for both the independent ombudsmen and those fulfilling ombudsman-like roles in the MCOs assume similar additional functions. These additional tasks include member/family education about the availability of services and how to access services and the complaints/appeals process. Both may also have duties related to tracking grievances and making recommendations for improvement to the provision of care. Exhibit 7 summarizes the ombudsman functions assumed by the state and MCOs in each program.

VI. Other Quality Considrations

As we talked with states a few other issues pertinent to quality in MLTSS emerged. The first of these was how aspects of their quality management system had developed since program inception. Several states' comments revolved around the evolution of performance measures. Michigan had decreased the number of measures dramatically over time, from approximately 50 to fewer than 20. They were motivated to scale back due the expense associated with the EQRO having to validate the larger number of measures.

Wisconsin told us that they had moved from relying exclusively on process measures to more of a balance between process and member outcome measures. Comments by two other states were more of an aspirational nature regarding future developments in measurement--one wishing to incorporate more outcome measures (Texas) and another hoping to use HCBS Experience of Care measures under development by CMS (Tennessee).²² Related to the discussions surrounding outcome measures was one state's observation that they had evolved their PIPs from an administrative focus to ones concentrating on quality of care improvements and health outcomes (Texas).

Other changes noted were increased standardization of MCO processes allowing for more effective state oversight (Wisconsin), expanding the EQRO's role (Texas), increasing the number and expertise of state monitoring staff (North Carolina), and developing an individually-based critical incident monitoring system (Michigan).

In addition, a couple of states (Tennessee, Texas) noted that MLTSS quality monitoring is much more data-driven and that they were using more sophisticated data systems for evaluating the provision of care than they had under the 1915(c) waiver programs. Tennessee in particular pointed to the EVV system (described earlier in this report) that it implemented at the outset of its MLTSS program. While not making any comparison to service receipt performance under the predecessor 1915(c) waiver, they cited recent performance of greater than 96% of scheduled in-home visits delivered, and 99.7% delivered on time. They attribute this achievement to the EVV system with the ability to resolve missed/late visits in real-time. More related to member health outcomes, Texas has empirical evidence of improved treatment of Chronic Obstructed Pulmonary Disease under its MLTSS program, and Pennsylvania cited an increase in competitive employment as a positive program impact.

Another topic we explored was states' experience with the flexibility afforded in the Medicaid managed care regulations for quality management as compared to the more prescriptive requirements associated with the 1915(c) HCBS waiver requirements. Tennessee acknowledged that the 1915(c) requirements influenced the design of their quality strategy but that they appreciated the ability to customize the quality management approach in their MLTSS program. North Carolina mentioned that the 1915(b) authority allows them to contract with select providers who offer higher quality care, whereas otherwise they would have to adhere to the "any qualified provider" stipulation under Medicaid FFS. And, at the time of our interview, Michigan was in discussions with CMS to substitute MCO accreditation for state audits, augmented by EQRO record reviews; that flexibility is not a current option under the 1915(c) waiver authority.

VII. Discussion

Diversity is a hallmark of the state-federal Medicaid program. The saying goes: "If you've seen one Medicaid program, you've seen one Medicaid program." In terms of MLTSS quality, the same holds true to a large extent. CMS has always accorded states discretion in the design and operation of their Medicaid programs, including quality monitoring, as long as they adhere to Medicaid regulations. States' responsibility to exercise administrative authority over their Medicaid programs is one of those expectations. Administrative authority requires that the Medicaid agency assume ultimate responsibility for oversight of any program functions it contracts out or delegates to other entities. But even administrative authority can be implemented in a manner as seen fit by a particular state, as long as approved by CMS.

Flexibility is also an underlying tenet of Medicaid MLTSS--affording MCOs opportunity to coordinate and deliver care in innovative ways suitable to the needs and desires of beneficiaries with long-term disability. Flexibility encourages innovation and allows the states and MCOs to be responsive to local conditions, cultures and the diversity of the MLTSS population. CMS acknowledges that states have options for how they address the essential elements of a MLTSS program outlined in its recent guidance document. Not surprising, across the programs studied we found a fair amount of variability in how states structure quality oversight in their MLTSS programs. By and large, however, all have integrated into their quality strategies the quality-related structures and processes delineated by CMS' guidance on the essential elements in MLTSS programs--but differently.²³

While it would be imprudent to stifle diversity in how states design their quality infrastructures, processes and procedures, an argument can be made for more uniformity in measuring the impact of MLTSS on beneficiaries' lives, particularly outcomes related to health, experience of care and quality of life. In the commercial health marketplace as well as in Medicaid and Medicare, there has been a convergence toward adoption of rigorously tested health effectiveness and experience of care metrics as exemplified by Health Effectiveness Data and Information Set (HEDIS) and Consumer Assessment Health Care Providers and System (CAHPS),²⁴ respectively. Measures as these allow for "apple-to-apple comparisons" across providers, plans and states and are widely used by commercial plans, hospitals, providers and federally-funded programs across the nation.²⁵ Another initiative along these lines is CMS' recent specification of a core set of health care quality measures for Medicaid-eligible adults as required by Section 2701 of the Affordable Care Act.²⁶ Items in this set are based largely on previously tested items and draw upon both HEDIS and CAHPS. However, the focus of these measures is on health care, not on LTSS. To fill this gap, CMS has invested in the development and testing of an HCBS Experience of Care survey for Medicaid programs for which CAHPS certification will be sought. This initiative will result in a cross-population survey so that "apples-to-apples" comparisons can be made across programs that serve the frail elderly, adults with disability, and persons with IDD. The instrument will be appropriate for use in both the FFS and MLTSS settings and thus will afford comparison between consumer-experiencedcare in those environments as well. At least one of the MLTSS programs in our study was intending to participate in the testing of this new survey.

In closing, we reiterate that the quality enterprise in MLTSS--for states, MCOs, providers and EQROs--is one with multiple and simultaneously moving parts. It requires sufficient investments in personnel and information technology resources as well as leadership's commitment to keep all engaged and aligned. As this report demonstrates, there are several tacks that states can take for assessing MCO and provider performance and for monitoring member well-being. We hope that the information on the myriad of ways states structure MLTSS quality management will be helpful to states embarking upon new programs as well as to those established programs that may be taking a second look at different options for quality.

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Mission Analytics Group. (February 2013). The Balancing Incentive Program: Implementation Manual. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long.... Accessed September 26, 2013.

This manual provides guidance to states in implementing the three structural changes in their systems of community-based LTSS: a No Wrong Door/Single Entry Point (NWD/SEP) eligibility determination and enrollment system; Core Standardized Assessment Instruments; and Conflict-Free Case Management..

National Committee for Quality Assurance. (March 2013). Integrated Care for People with Medicare and Medicaid. http://www.ncqa.org/portals/0/public%20policy/NCQAWhitePaper-IntegratedCareforPeoplewithMedicareandMedicaid.pdf. Accessed September 26, 2013.

This paper reviews strategies for measuring and evaluating quality and person-centeredness in integrated care systems.

National Home and Community-Based Quality Enterprise. (April 27, 2012). NQE Quality Brief: Mortality Investigation and Review in Medicaid Home and Community-Based Services Program.

This brief outlines issues states should consider when developing mortality investigation and review policies and procedures for Medicaid HCBS participant deaths.

Rivard, P., Jackson, B., Rachel, J., Seibert, J., Whitworth, T. (September 2013). Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Truven Health Analytics.

This report summarizes the quality requirements that states include in their contracts with MCOs for their Medicaid MLTSS programs.

Saucier, P., Kasten, J. Burwell, B., Gold, L. (2012). The Growth of Managed Long Term Services and Supports (MLTSS) Programs: A 2012 Update. Centers for Medicare and Medicaid Services. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/MLTSSP_White_paper_combined.pdf. Accessed August 8, 2013.

This paper reports the findings of a national environmental scan of all Medicaid MLTSS programs implemented as of June 2012 and a projection of future programs through January 2014.

Synovate. (April 10, 2009). Arizona Long Term Care System (ALTCS) Satisfaction Survey 2008: Report of Findings. http://www.azahcccs.gov/shared/Downloads/surveys/ALTCS_Satisfaction_Survey_2008-FullReport.pdf. Accessed August 22, 2013.

This report highlights the findings from a survey on satisfaction with care and services provided by the ALTCS for the Elderly and Physically Disabled (ALTCS-EPD) program and represent input from members across all eight ALTCS-EPD program contractors in all three of the care settings in which members reside (nursing facility, assisted living, and home).

Texas Medicaid Managed Care STAR+PLUS Behavioral Health Survey Report Fiscal Year 2011. http://www.hhsc.state.tx.us/reports/2013/EQRO-Behavioral-Health-FY2011.pdf. Accessed July 17, 2013.

This report, prepared by the Texas' EQRO, provides results from the state fiscal year 2011 STAR+PLUS Behavioral Health Survey which documents customer satisfaction and experience of behavioral health services.

Texas Medicaid Managed Care STAR+PLUS Home- and Community-Based Services Waiver Study Report Contract Year 2012. http://www.hhsc.state.tx.us/reports/2013/EQRO-STAR-PLUS-Waiver.pdf. Accessed July 17, 2013.

The purpose of this study was to: (1) describe and categorize the types of HCBS provided to Texas STAR+PLUS members; (2) examine perceptions STAR+PLUS members and service coordinators about the process of developing an ISP; (3) assess the involvement of members and their families in decisions regarding their care; and (4) assess members' experiences and satisfaction with the HCBS they receive.

Texas STAR+PLUS Program Adult Member Survey Report, Fiscal Year 2011. http://www.hhsc.state.tx.us/reports/2012/EQRO-Texas-STARPLUS-Audlt-Member-Survey-FY2011-Attachment-1.pdf. Accessed July 17, 2013.

This report provides results from the fiscal year 2011 STAR+PLUS Adult Member Survey and offers information on health status as well as member experiences and general satisfaction with the care they receive through the Texas STAR+PLUS program.

Truven Health Analytics (as The MEDSTAT Group, Inc.). Participant Experience Survey (PES) Tools. For the Centers for Medicare and Medicaid Services. http://nasuad.org/hcbs/article/participant-experience-survey-pes-tools. Accessed March 5, 2014.

These interview tools capture feedback directly from waiver participants about the supports and services they receive through home and community-based services waivers. States can use the data gathered through the surveys to calculate performance indicators to monitor quality within waivers. There is one PES geared for frail elderly and adults with physical disabilities and one for adults with intellectual and/or developmental disabilities.

Under Development by the National Association of State Units on Aging and Disability--NCI-AD--Expanding the National Core Indicators for Aging and Disability Services. Presented at the 2013 NASUAD HCBS Conference. http://www.nasuad.org/documentation/HCBS_2013/Presentations. Accessed October 11, 2013.

This presentation addressed expanding the National Core Indicators for the aged and disabled populations.

Wisconsin Department of Health Services, Family Care. 2010 Family Care Member Satisfaction Survey Results. http://www.dhs.wisconsin.gov/LTCare/Reports/PDF/satisfactionrpt2010.pdf. Accessed June 10, 2013.

This report discusses the program findings and methodology of the satisfaction survey conducted by the State of Wisconsin on its Family Care MLTSS program.

Wisconsin Department of Health Services. Family Care Contract between Department of Health Services Division of Long Term Care and <<Name of MCO>>. http://www.dhs.wisconsin.gov/ltcare/statefedreqs/cy2012mcocontract.pdf. Accessed June 21, 2013.

This document is the Family Care Contract between the Wisconsin Department of Health Services and MCOs. It includes contract requirements for MCO governance, consumer and member involvement, eligibility, enrollment and disenrollment, among others.

Wisconsin Department of Health Services, Division of Long-Term Care. Long-Term Care In Motion: Wisconsin's Long Term Care Programs. http://www.dhs.wisconsin.gov/publications/P0/p00318_2011.pdf. Accessed June 21, 2013.

2011 report on Wisconsin's IRIS and Family Care Programs.

Zubritsky, C., Abbott, K., Hirschman K., Bowles K., Foust, J., Naylor, M. (2012). Health-Related Quality of Life: Expanding a Conceptual Framework to Include Older Adults Who Receive Long-Term Services and Supports. The Gerontologist, 53(2): 205-210. http://gerontologist.oxfordjournals.org/content/53/2/205.full.pdf+html. Accessed May 13, 2013.

Journal article exploring multi-dimensional health-related quality of life models and concepts.

Notes

1. Saucier P., Kasten J., Burwell B., and Gold L. 2012. The Growth of Managed Long Term Services and Supports (MLTSS) Programs: A 2012 Update. Centers for Medicare and Medicaid Services. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/MLTSSP_White_paper_combined.pdf. Accessed August 8, 2013.

2. Medicaid managed care regulations may be found in Code of Federal Regulations (CFR) 438: http://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol4/CFR-2011-title42-vol4-part438/content-detail.html. Accessed August 30, 2013.

3. Centers for Medicare and Medicaid Services, Center for Medicaid & CHIP Services, 2013. Guidance to States Using 1115 Demonstrations or 1915(b) Waivers for Managed Long Term Services and Supports Programs. May 20, 2013. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Delivery-Systems/Downloads/1115-and-1915b-MLTSS-guidance.pdf. Accessed August 30, 2013.

4. While we use the term "MCO" in this report to refer to entities who manage MLTSS services under contract to the state, technically the plans in Michigan, North Carolina and Pennsylvania are Pre-paid Inpatient Health Plans (PIHPs).

5. Rivard P., Jackson B., Rachel J., Seibert J., and Whitworth T. Environmental Scan of MLTSS Quality Requirements in MCO Contracts. Truven Health Analytics, Draft: August 31, 2013.

6. AHCCCS--Arizona Health Care Cost Containment System.

7. AAADs are responsible for information and referral activities and sit outside the MCOs.

8. Money-Follows-the-Person Demonstration.

9. National Committee for Quality Assurance. Integrated Care for People with Medicare and Medicaid. March 2013. http://www.ncqa.org/portals/0/public%20policy/NCQAWhitePaper-IntegratedCareforPeoplewithMedicareandMedicaid.pdf. Accessed September 26, 2013.

10. Lind A, Gore S, Barnette L, and Sommers S. Profiles of State Innovation: Roadmap for Managing Long-Term Supports and Services. Center for Health Care Strategies. November 2010. http://www.chcs.org/usr_doc/MLTS_Roadmap_112210.pdf. Accessed September 26, 2013.

11. Dembner A. Putting Consumers First Promising Practices for Medicaid Managed Long-Term Services and Supports, Community Catalyst. January 2013. http://www.communitycatalyst.org/doc_store/publications/putting_consumers_first_LTSSmanagedcare.pdf. Accessed September 26, 2013.

12. Konetzka RT, Karon SL, and Potter DEB. Users of Medicaid Home and Community-Based Services Are Especially Vulnerable to Costly Avoidable Hospital Admissions. Health Affairs 31, 2012. http://content.healthaffairs.org/content/31/6/1167.full.

13. Galantowicz S. Environmental Scan of Measures for Medicaid Title XIX Home and Community Based Services: Final Report. AHRQ Publication No. 10-0042-EF. Agency for Healthcare Research and Quality, Rockville, MD. June 2010. http://www.ahrq.gov/research/ltc/hcbsreport. Accessed June 26, 2013.

14. Maslow K, Ouslander J. Measurement of Potentially Preventable Hospitalizations. Long-Term Care Quality Alliance. January 2012. http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images/PreventableHospitalizations_021512_2.pdf. Accessed September 26, 2013.

15. Centers for Medicare and Medicaid Services, Code of Federal Regulations, 42 CFR 438.206.c.1.i-vi.

16. Government Accountability Office. Medicaid Home and Community-Based Waivers: CMS Should Encourage States to Conduct Mortality Reviews for Individuals with Developmental Disabilities. GAO-08-529 May 23, 2008.

17. National Home and Community-Based Quality Enterprise. NQE Quality Brief: Mortality Investigation and Review in Medicaid Home and Community-Based Services Program. April 27, 2012.

18. AAAD (Tennessee).

19. FEA, for members directing their own services (Tennessee).

20. CFR 438.240.

21. Mission Analytics Group. The Balancing Incentive Program: Implementation Manual. February 2013. http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Long.... Accessed September 26, 2013.

22. Centers for Medicare and Medicaid Services. Planning and Demonstration Grant for Testing Experience and Function Tools in Community-Based Long Term Services and Supports (TEFT) (CMS-1H1-13-001). June 27, 2013. http://www.grants.gov/web/grants/view-opportunity.html?oppId=195253. Accessed September 26, 2013.

23. In those instances where a state appears not to have implemented all the essential quality elements delineated in CMS' guidance document, we remind the reader that our data collection occurred prior to, and approximately contiguous with, the release of CMS' directive in May 2013. As such, this study's description of state practices (or their absence) to assess compliance with federal expectations should be avoided.

24. CAHPS is actually a family of measure sets, focusing on consumers' experience with different aspects of the health care delivery. Separate CAHPS instruments have been developed and tested for assessing consumer experience of health plans, hospitals, dental services, Medicaid, home health, nursing home, prescription drug plan, clinician and group, behavioral health, patient-centered medical home, and Medicare Advantage plans.

25. Thurston Toppe, K. NCQA Medicaid Managed Care Toolkit. National Committee for Quality Assurance. March 2012. http://www.ncqa.org/Portals/0/Public%20Policy/2012_NCQA_Medicaid_Managed_Care_Toolkit_Summary_-_March_2012_Final.pdf. Accessed September 26, 2013.

26. Centers for Medicare and Medicaid Services. Initial Core Set of Health Care Quality Measures for Adults Enrolled in Medicaid (Medicaid Adult Core Set). http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-Topics/Quality-of-Care/Downloads/Medicaid-Adult-Core-Set-Manual.pdf. Accessed September 26, 2013.

27. The state legislature mandated that as of October 1, 2013, the number of PIHPs will be reduced to ten new regional entities for simplification and equity statewide and to prepare mental health and developmental disability systems for increased integrated care approaches.

28. The PIHPs must also be a designated Community Mental Health Services Program.

29. The QIC is a stakeholder group comprised of consumers, advocates, provider organizations, PIHPs and Community Mental Health Service Programs.

Appendices

Appendix A. Arizona Long-term CARE System

Appendix B. Michigan's Managed Specialty Supports and Services

Appendix C. Minnesota Senior CARE Plus and Minnesota Senior Health Options

Appendix D. North Carolina's 1915(b)/(c) Medicaid Waiver for Mental HEALTH/ Developmental DISABILITIES/SUBSTANCE Abuse Services

Appendix E. Pennsylvania's Adult Community Autism Program

Appendix F. Tennessee's Choices in Long-term CARE

Appendix G. Texas's Star+plus Program

Appendix H. Wisconsin's Family CARE