SPRING 2017 supplement 1

Journal of the American Society on Aging

The Field Guide to

Managed Care:

A Primer

The past, present, and future of community-based organizations

How to form partnerships and prepare a service model

Helping hands: how foundations and government

support CBOs on the path to managed care

The Field Guide to Managed Care: A Primer

ASA Executive Committee Chair, Board of Directors: Robert B. Blancato, Washington, DC Chair-Elect: Karyne Jones, Washington, DC Immediate Past Chair: Lynn Friss Feinberg, Washington, DC Secretary: Robert E. Eckardt, Cleveland, OH Treasurer: Lisa Gables, Alexandria, VA

ASA Board of Directors Jean Accius, Washington, DC Michael Adams, New York, NY Cynthia Banks, Los Angeles, CA William Benson, Wheaton, MD Richard Browdie, Cleveland, OH Hassy Cohen, M.D., Los Angeles, CA Paul Downey, San Diego, CA Brian M. Duke, Radnor, PA Stacey Easterling, St. Louis, MO Joyce Gallagher, Chicago, IL Brooke A. Hollister, San Francisco, CA Cynthia L. Hutchins, Bel Air, MD Karen N. Kolb Flude, Chicago, IL Rebecca C. Morgan, Gulfport, FL Scott Peifer, San Francisco, CA Joy Powell, Franklin, TN

Kevin Prindiville, Oakland, CA John Rother, Washington, DC John M. Thompson, Atlanta, GA President and CEO: Robert G. Stein, San Francisco, CA

GENERATIONS STAFF Publisher: Robert G. Stein Editor: Alison Hood Senior Editor: Alison Biggar

Typography & Production: Acacia Graphics & Design, San Francisco Generations cover and book design by Lisa Rosowsky, Blue Studio.

Front cover image © Getty images dane_mark © 2017 American Society on Aging

Union Bug

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inside generations f ie ld guide suppl ement 1 The Field Guide to Managed Care: A Primer

3 Managed Care: The Business of Providing Quality Supports and Services to Older Adults

34 How to Develop the Infrastructure to Support and Implement the Managed Care Service Model By Elaine Clark 39 Developing the Contract, Contingency Plan, and Relationship Management Plan By Jamie Almanza

the world of quality care: history, landscape, outlook

5 Community-Based Organizations, from Past to Present to Future By Gretchen E. Alkema 10 The Big Shift: What Is the Landscape and Potential of Managed Care? By Stephen A. Somers and Nancy Archibald 16 Who Cares? Implications of Managed Care for Organizations and the Communities They Serve By Jennifer Dexter

managed care models in action

42 A Helping Hand: CBOs Receive Philanthropic Support on Their Path to Managed Care By Nora OBrien-Suric 48 Preparing Aging and Disability Organizations for Delivery System Reform By Marisa Scala-Foley 52 Case Study: San Diego County’s Cal MediConnect Pilot By Kristen D. Smith 56 Case Study: One AAA’s Journey Toward Managed Care By Connie Benton Wolfe 61 Case Study: The Indiana Association of Area Agencies on Aging By Kristen LaEace 65 The Common Denominator: A Secret Sauce for Success By W. June Simmons and Sandy Atkins

20 The Case for Building a Mindset of Change: Not Just Business as Usual By Bradley Gilbert

next steps and challenges: identifying and building competencies for high-value partnerships 25 Developing a Model Concept and Clientele, with Potential Partners and Services By Erin Lockwood and Lori Peterson

30 Pricing Strategies for LTSS Providers By Victor Tabbush

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Managed Care: The Business of Providing Quality Supports and Services to Older Adults A ging services providers have always addressed the needs of the popula- tions they serve with a “mission-driven, humanistic, and customer-service orientation,” says The SCAN Foundation’s

for Community Living (ACL), the Gary and Mary West Foundation, the Marin Community Foundation, and the Colo- rado Health Foundation. All partners have united to fund a three-year grant to develop and establish the Aging and Disabilities Business Institute, which is housed within the National Association of Area Agencies on Aging (n4a); aging Two future field guides will build upon the information we now have, providing new insights and more resources. This Field Guide parses the land- scape of managed care: what it is, why it is necessary, and how community- based organizations (CBO) and health- care entities are partnering to effect it. As well, real-life case studies share lessons CBOs have learned in their journeys to managed care, and offer thoughts on what the future of man- aged care might hold. This primer is divided into three sections that walk readers through this “new” managed care terrain. The con- tent of Section One, “The World of Quality Care: History, Landscape, Outlook,” was guided by Gretchen Alkema, vice president of Policy and Communications at The SCAN Founda- tion, who in addition to this advisory role contributed an overview of the aging services network, past, present, and future (see her article on page 5). “Older Americans today are living dramatically longer than their parents

‘As we . . . prepare for our own aging, health systems can help by focusing on what people want and need as they pursue the highest quality and care value.’

Gretchen Alkema in the opening article of this supplemental issue of Generations . But as funding for the Older Americans Act has flat- tened out, these same providers must find a way to become more self- sustaining. A way forward is through seeking and

building business partnerships with healthcare delivery systems and provid- ers to offer integrated, or managed, care. This is a long road—one with challenging twists and turns—for community-based providers moving toward fully integrated care. And there are many secrets to success—among them, collaboration, experimentation, and open-minded persistence—as shown in the articles and case studies in this supplement, “The Field Guide to Managed Care: A Primer.” The American Society on Aging (ASA) is pleased to offer this supple- ment to its regular quarterly publication of Generations journal. The Field Guide has been supported by a collaboration of The SCAN Foundation, The John A. Harford Foundation, the Administration

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did, often complicated by multiple chronic conditions and daily functional challenges,” says Alkema. “As we—individuals, families, and society as a whole—prepare for our own aging, health systems can help by focusing on what people want and need as they pursue the highest quality at the best value. This approach includes putting the person needing support in the middle of the care experience, and building more connected systems of personalized support using the right mix of medical and non-medical providers.” Erin Westphal, program officer at The SCAN Foundation, helped shape Section Two, “Next Steps and Challeng- es: Identifying and Building Competen- cies for High-Value Partnerships.” This section covers the specifics of how to develop models, set pricing, and imple- ment and manage relationships within integrated care collaborations. “Various policy actions have changed the landscape for delivering services to older adults and people with disabilities, creating new opportunities for high-value partnerships and making it imperative that we foster competen- cies across groups and develop the in- frastructure for smooth integration of services,” says Westphal. “The Linkage Lab (www.thescan foundation/linkage-lab-initiative), Care Excellence (https://careexcel, and other programs exist to prepare CBOs, care managers, and others to successfully manage collabo- rations that are becoming more com- mon and important.” For Section Three, “Managed Care Models in Action,” Brenda Schmitt-

henner, program officer, Successful Aging, for the Gary and Mary West Foundation, found stellar case studies showing how CBOs and Area Agencies on Aging have progressed through the managed care process. Also included are articles that enumerate philanthropic support for organizations shifting to managed care, how the federal ACL is lending support, and one foundation’s reflection on what lies ahead for the future of community-based services. “The healthcare landscape in this (MCO) to control Medi- caid expenditures for a growing population of older adults and persons with disabilities who re- quire long-term services and supports [LTSS],” says Schmitthenner. “Many trailblazing CBOs have seized the opportunity to deliver services like care transitions, care management, and nutrition to high-risk health plan members by executing contracts with MCOs. Their experiences provide valuable learnings and opportunities for replication to sustain essential LTSS.” As June Simmons, founding partner and CEO of Partners in Care Founda- tion, says in her closing article (see page 65), “Integrating healthcare and social services around the needs, goals, and preferences of people with chronic conditions is closer to being achieved than ever before.” country has changed dramatically in recent years, with more states looking to Managed Care Organizations

‘Various policy actions have changed the landscape for delivering services to older adults and people with disabilities, creating new opportunities for high-value partnerships.’

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Community-Based Organizations, from Past to Present to Future

By Gretchen E. Alkema

Aging network service providers now must become business-minded entities that foster sustainable partnerships and forge successful outcomes.

I t was the summer of 1965. President Lyndon B. Johnson was making headway on his War on Poverty, with the development and passage of Medicare and Medicaid, creating more afford- able and accessible healthcare coverage for older and low-income Americans. But another law was emerging that set a monumental vision to champion the dignity and independence of our aging nation: The Older Americans Act (OAA). Many CBOs emerged or greatly expanded as the OAA created a dedicated and predictable funding stream for their services. The OAA was developed after policy makers expressed intense concern about a lack of com- munity social services for older people. In the 1950s and early 1960s, policy makers and advocates increasingly recognized that older Americans were a growing proportion of the population and that their needs were not being

addressed through existing programs. The OAA articulated ambitious goals to promote the well-being of individuals ages 60 and older through retirement security, healthy living, stable housing, meaningful community engage- ment, and more. On July 14, 1965, upon signing the OAA, which passed with substantial bipartisan support, President Johnson said the law would provide: . . . an orderly, intelligent, and constructive program to help us meet the new dimensions of responsibilities which lie ahead in the remaining years of this century. Under this program every state and every community can now move toward a coordinated program of services and opportunities for our older citizens (Johnson, 1965). How could this be accomplished while honoring the heterogeneous nature of older Americans and the communities where they resided? Using federalism as its guide, the OAA created a federal-state administrative architec- ture that fostered planning and program imple- mentation based on local-level needs and a

abstract The aging network, developed and initially sustained through the Older Americans Act, is a major vehicle for organizing and delivering services to help older adults receive the support they need to live well in their homes and communities. Policy and regulatory changes have created challenges and opportunities for the aging network. New opportunities for innovation and revenue generation include partnerships with the healthcare sector, which suggests it is time for the network to transform toward business-minded operations, while maintaining its charitable heart. | key words : aging network, community-based organizations, managed care, healthcare, transformation

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Easterseals, Jewish Family Services, Volunteers of America), many others emerged or greatly expanded as the OAA created a dedicated and predictable funding stream for their service platform. Since the early 2000s, OAA funding has remained stagnant relative to the growing demographic of older Americans. (Fox-Grage and Ujvari, 2014). Currently, the OAA budget ($1.9 billion) is comparable to about one day’s worth of Medi- care spending (HHS, 2016). Additionally, the OAA budget is granted unevenly across states through a congressionally defined formula, which has been a point of contention during the last few reauthorizations (Napili and Collelo, 2012). The widening differential between mod- est OAA funding levels over time and anti- cipated need for services as the population ages have led to various policy and operational responses, as follows: targeting only the highest need individuals; greater reliance on philan- thropic support; and active consideration of alternative funding sources. While CBOs in the aging network range in depth of expertise, service platforms, staffing types and levels, as well as in community integration, the network as a whole has developed strength throughout its tenure. Service providers are generally from nonprofit organizations that fill a unique role in their communities. They often balance a service portfolio addressing the needs of various populations through a localized ap- proach with a mission-driven, humanistic, and customer-service orientation. Rooted in com- munities, these providers are sensitive to local context and nuances across population segments, and often have built a solid trust and engagement. OAA funding and its associated service delivery requirements have created the basic service structure for these organizations, yet each takes its own approach on how services are delivered. Some work in partnership with health, housing, Benefits and Challenges of the 21st Century Aging Network

variety of services. The Administration on Aging (part of the Administration for Community Liv- ing, or ACL, within the Department of Health and Human Services [HHS]) is the federal focal point for implementing the law and considering health-related matters affecting older adults (National Health Policy Forum, 2012). Fifty-six states and territories receive OAA funds for community planning and social ser- vices, research and development projects, and workforce training. These dollars are passed down to more than 600 area agencies on aging and 200 tribal organizations that partner with nearly 20,000 providers for myriad community- oriented services—caregiver support, elder abuse prevention, home-delivered and congre- gate meals, job training, medication manage- ment, preventive health services, transportation, and more (ACL, 2015). This “aging network” is a major vehicle for organizing and delivering services that help older adults with daily living needs receive the support they need to live well in their homes and communities. While some community-based organizations (CBO) have existed for nearly 100 years (e.g.,

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and city service providers, with staff frommore sophisticated organizations being able to break through service impasses to help clients get needs met (e.g., they may have back-channel access to county social services staff to help expedite a review for Medicaid eligibility). Leading organizations have also implement- ed evidence-based programs to decrease depres- sion, mitigate falls, better manage chronic health conditions, and address medication-related problems—all of which show promise in the network’s ability to directly improve functional outcomes for older adults (National Council on Aging, 2016). The aging network faces several interrelated challenges that have hampered its ability to man- age and lead change in the current political, policy, and fiscal climates. First is the network’s long-standing dependence on OAA grants for core operational sustainability, coupled with a 1970s accountability framework, requiring that organizations report the number of services provided instead of outcomes achieved. As OAA funds stagnated in each federal budget cycle, organizations initially spent significant time seeking new funding to backfill needs, as well as making hard decisions to not serve older adults in need, to stop some services, and, in extreme cases, to close their doors. Aging services providers must illustrate the value of their services in reducing costs elsewhere in the larger healthcare system. The persistence of flat OAA funding has forced organizations to choose between trying to continue “business as usual” or become a more business-focused entity—both of which risk significant financial instability. Some are begin- ning to embrace the concept of “no margin, no mission,” yet struggle with having the time, financial stability, and expertise to engage in introspection about who and what they are as an organization and translate that into transfor-

mation. Transforming such organizations is a significant challenge. It involves rethinking leadership and management approaches, as well as staffing needs and patterns, clarifying and communicating about services offered, reaching out to new customer bases for diverse revenue sources, and defining quality and outcome thresholds for services. Last, much of the transformation needed depends upon a new, evolving resource—a robust and protected technological infrastruc- ture. The number of meals served, rides pro- vided, or care management visits delivered no longer defines success. Instead, aging services providers must now illustrate the value of their services in reducing costs elsewhere in the larger healthcare system. As a result, there is increased importance placed on providers’ ability to maintain client records, complete billing to third-party payers, assess and monitor quality measures, and communicate seamlessly with other providers. New Opportunities for the Aging Network A core tenet of the 2010 Patient Protection and Affordable Care Act (ACA) was to transform how Medicare- and Medicaid-funded services are delivered to achieve better care quality, while at the same time reducing overall care costs. Its premise was to change payment models

for care, shifting from a “volume of services” mentality to focusing on the value health plans and systems provide. Value-based care for hospitals and health systems was initially defined as a reduc-

tion in inappropriate hospital admissions and emergency room visits, particularly thirty-day readmissions rates for the same health condition. The ACA created the Innovation Center within the Centers for Medicare & Medicaid Services, which has been the incubator and funding source for most of the value-based payment models and delivery system arrange- ments, such as integrated care demonstrations for those with dual eligibility, the bundled

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payment initiative between hospitals and post- acute care, and various care management–based demonstrations across the states. Concurrently, several states have asked for federal approval to reconfigure operations of their Medicaid prog- ram. Many states have contracted with managed care companies to accept operational and fiscal responsibility for Medicaid services—both for healthcare and long-term services and supports (LTSS). Currently, Medicaid-managed LTSS is the primary vehicle that delivers daily living support for low-income older adults with functional needs. All of these policy and regulatory knowledge, and enduring commitment to local- oriented services with a primary goal of help- ing individuals in need live well in community. Beyond the necessity of quality care, health plans and systems (such as Accountable Care Organiza- tions) also have a financial incentive to ensure their members are thriving in the community, especially after a major medical intervention. changes have created substantial oppor- tunities for the aging network because of their established presence, depth of

Health plans involved in the integration of Medicare and Medicaid services are particularly responsible for the total set of health and func- tional outcomes of their members. Innovative health plans and systems are fostering partner- ships with CBOs that help members with the transition from hospital to home, provide follow- up care management and family caregiving support, arrange for personal care and home modifications where necessary, and help identify functional decline before this becomes an emergency situation. For health plans and systems to use the aging network well, they need to better understand what services the network offers to support older adults with chronic health conditions and daily living needs, and how to best contract with these providers. The aging network must assess the needs of the healthcare sector and demon- strate the value they bring in providing localized Leading and managing change will be the core of the aging network’s success.

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services to meet well-defined health and func- tional outcomes. In addition, the network needs to be ready for this new kind of partnership, which requires a different kind of operational model for success. Several new initiatives, in- cluding the National Aging and Disability Busi- ness Institute (aginganddisabilitybusinessinsti, provide trainings, an ongoing webinar series, and technical assistance to aging network organizations to help them create and renovate their business models to become effective part- ners with healthcare entities. Looking Forward The aging network is experiencing a fundamen- tal transition—one in which leading and manag- ing change will be the core of its success. It is time for the network to ramp up to a business- minded operational structure, while maintaining at its center a charitable heart. Partnerships with the healthcare sector give CBOs new opportu- nities for innovation and revenue generation. However, healthcare will not likely pay for the breadth of aging services that the network is ac- customed to providing through OAA funding.

This transition to new business models and pay- ment structures will be difficult, and not all or- ganizations in the network will survive. It will take strong leadership, a dedicated sense of mission, adaptability, creativity, collaboration, persistence, patience, and a willingness to con- tinually experiment. The good news is that the organizations that comprise the aging network—that form its heart and soul—have the fortitude and determination to accept this challenge. During one of her final speaking engagements, Assistant Secretary for Aging Kathy Greenlee talked about what the net- work carries as it marches into a new future: We are an amazing group of talented, caring people. We have each other’s backs. We share ideas and inspiration. We give hugs and pep talks. We brainstorm and vent. We laugh together . . . and sometimes we cry. . . . We pick ourselves up and try. We have attitude, dignity, and leadership (Greenlee, 2016). Gretchen E. Alkema, Ph.D., L.C.S.W., is vice president of Policy and Communications at The SCAN Founda- tion in Long Beach, California.

References Administration for Community Living (ACL). 2015. The Older Americans Act: Aging Well Since 1965. Observances/OAA50/docs/ OAA-Brief-Final.pdf. Retrieved September 30, 2016. Fox-Grage, W., and Ujvari, K. 2014. Insight on the Issues: The Older Americans Act. AARP Public Policy Institute. dam/aarp/research/public_policy_ institute/health/2014/the-older- americans-act-AARP-ppi-health. pdf. Retrieved October 9, 2016.

National Council on Aging. 2016. Center for Healthy Aging. NCOA. aging/. Retrieved October 9, 2016. National Health Policy Forum. 2012. “The Basics: Older Ameri- cans Act of 1965.” library/the-basics/Basics_Older AmericansAct_02-23-12.pdf. Retrieved October 9, 2016 U.S. Department of Health and Human Services (HHS). 2016. HHS FY2016 Budget in Brief. Centers for Medicare & Medicaid Services. budget/budget-in-brief/cms/ medicare/index.html. Retrieved October 9, 2016.

Greenlee, K. 2016. “Leaving a Legacy: Forging New Partnerships Beyond the Aging Network.” Key- note remarks, “Answers on Aging Conference,” from the National Association of Area Agencies on Aging, San Diego, CA, July 26. Johnson, L. B. 1965. Public Papers of the Presidents of the United States: Lyndon B. Johnson, 1965. Vol. 2. U.S. Government Printing Office. 1963–1969. www.presiden 27079. Retrieved October 9, 2016. Napili, A., and Collelo, K. J. 2012. Funding for the Older Americans Act and Other Administration on Aging Programs. Washington, DC: Congressional Research Service.

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The Big Shift: What Is the Landscape and Potential of Managed Care?

By Stephen A. Somers and Nancy Archibald

Team-based, integrated care can be crucial for older adults with multiple chronic conditions, but CBOs need to build business skills before fully participating in this type of care.

O ver the past two decades, Medicare and Medicaid—the primary insurers of health- care and long-term services and supports (LTSS) for older Americans—have progressively shifted their payment arrangements from fee-for-service (FFS) to managed care. This shift has important implications not just for beneficiaries, but also for the providers and community-based organi- zations (CBO) that serve older adults; these or- ganizations must adapt their business models to succeed in this new environment. The goals of managed care have changed, too. Originally focused on managing service use, managed care is now oriented toward delivering integrated, team-based care. There is a growing recognition among Medicare and Medicaid pur- chasers and plans that individuals with complex care needs, including older adults with multiple chronic conditions and younger individuals with disabilities, can benefit from the integration of services a managed care program can provide. Consequently, the range of services provided

by managed care organizations has expanded from primary and acute care to behavioral health and LTSS. Managed care’s increasingly team-based focus and its extended array of covered services call for the involvement of a broad range of community-based providers, particularly in the LTSS arena. However, these providers may have little experience working in a managed care environment. This article presents an overview of the managed care landscape, how managed care serves older adults, and the future of man- aged care for this population, in an effort to help CBOs better position themselves within this shift- ing terrain.

The Current Landscape: Medicare and Medicaid Managed Care

In the Medicare program, Medicare Advantage (MA)—the managed care alternative to Original Medicare (i.e., FFS)—has become an increasingly popular choice for beneficiaries. Enrollment in

abstract Older adults increasingly receive healthcare and other services through Medicare and Medicaid managed care delivery systems. The team-based, integrated care offered by managed care plans can be crucial to coordinating services for older adults, many of whom have multiple chronic conditions and needs for long-term services and supports. Community-based providers can play a key role in integrated care, but may have to build their breadth of knowledge and business skills before they can fully participate in managed care arrangements. | key words : managed care, community-based providers, older adults

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ing new populations, including older adults and people with disabilities, into Medicaid managed care programs (Snyder and Rudowitz, 2016). In 2014, the most recent year for which data are available, there were forty-five states with comprehensive Medicaid managed care pro- grams that enrolled 60 percent of Medicaid beneficiaries in the United States (Centers for Medicare & Medicaid Services [CMS], 2016a). Older adults often enroll in managed care either through MA or state-based Medicaid managed LTSS (MLTSS) programs. For the most part, these Medicare and Medicaid managed care programs operate independently, cover differ- ent types of services, and have different require- ments and standards. Medicare Part C—is offered by private insurance plans and covers all of the services that Original Medicare covers under Medicare Parts A, B, and D: emergency department care; inpatient hos- pital care; home healthcare; and a limited num- ber of days in a skilled nursing facility (all under Medicare Part A); physician visits, and other outpatient care (under Medicare Part B); and prescription drugs (under Medicare Part D). Enrollment in Medicare Advantage (MA) plans grew from 9.7 million in 2008, to 17.6 million in 2016. Types and features of managed care for all older adults Medicare Advantage Medicare Advantage—otherwise known as MA plans may contract with community-based providers to conduct the health risk assessments required of all new enrollees, or to provide ser- vices such as home healthcare. MA enrollment is voluntary. Beneficiaries can sign up for a MA plan during the annual open en- rollment period (October 15 through December 7) and can disenroll from their MA plan and return

MA plans grew from 9.7 million in 2008, or 22 percent of Medicare beneficiaries, to 17.6 million in 2016, or 31 percent of beneficiaries (Jacobson et al., 2016). MA offers beneficiaries a number of plan options, including some with low or no premiums (but with higher out-of-pocket costs). In addition, MA plans can offer supplemental benefits including vision, dental, hearing, and wellness coverage that may be attractive to older adults. MA also has a subtype of plans called Dual Eligible Special Needs plans, which enroll individuals with both Medicare and Medicaid; these are discussed below. On the other side of the ledger, states have created a variety of Medicaid managed care pro- grams providing comprehensive primary and acute care services, as well as specialty programs covering behavioral healthcare, dental, transpor- tation, and LTSS. An emerging trend is for states to fold physical health, behavioral health, and LTSS into one managed care contract covering all of these services. Also, states have been add-

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to Original Medicare during the Medicare Advan- tage Disenrollment period (January 1 through February 14). Other than a few special circum- stances, enrollees are locked in to their MA plan for the rest of the calendar year. In addition to the beneficiary protections in Original Medicare, MA plans offer a number of other protections. To ensure access to care, plans must meet network adequacy standards for the numbers and types of providers in their plans, as well as standards for provider proxim- ity to beneficiary residences. When a plan de- nies coverage of a service, it must explain the denial and what steps the beneficiary can take to appeal the decision. There is a five-level Medicaid MLTSS programs State-based Medicaid MLTSS programs are the other type of managed care program commonly serving older adults. An increasing number of states are using managed care for low-income older adults and people with disabilities who need LTSS, including institutional care and home- and community-based services (e.g., home health aide services, adult daycare pro- grams, personal care services, non-emergency medical transportation). As noted above, some MLTSS programs integrate LTSS with primary, acute, and behavioral healthcare. Enrollment in state Medicaid MLTSS pro- grams may be voluntary (as in Massachusetts’ Senior Care Options program) or mandatory (as in Tennessee’s TennCare CHOICES program). MLTSS enrollees are usually locked in to their managed care plan for one year. All Medicaid MLTSS programs have network adequacy stand- ards and a four-level appeals process, as well as other beneficiary rights and protections that vary by state. Last, states are required to devel- op care management requirements for person- appeals process that begins within the health plan and extends up to federal district court. MA enrollees also have the right to file a grievance against their plan or specific providers.

centered needs assessments, service planning, and service coordination consistent with federal guidance and regulations. Depending upon the state, the managed care organizations that participate in MLTSS pro- grams may contract with a wide variety of CBOs to provide services, including eligibility screen- ing, enrollment options counseling, in-home assessments, care planning, and care manage- ment and coordination. These providers are especially key given their role in addressing social determinants of health (e.g., poverty, unstable housing, food insecurity, low literacy) and, as a result, potentially improving overall health outcomes. To ensure access to care, MA plans must meet network adequacy standards for the numbers and types of providers in their plans. It is worth noting that Accountable Care Organizations (ACO), while not necessarily based on traditional capitated managed care arrangements, are another type of “managed” delivery structure that serves older adults. ACOs are provider-led models found predominantly in Medicare and, increasingly, in state Medicaid programs. ACOs seek to meet both quality and cost targets, and may be particularly useful in serving beneficiaries in areas with low rates of managed care penetration. States are interested in exploring how ACOs could partner with CBOs to provide care coordination and other supports to prevent hospital readmissions.

How Managed Care Serves Dually Eligible Beneficiaries

Close to 6 million individuals older than age 65 receive services from both the Medicare and Medicaid programs. For these dually eligible individuals, Medicare broadly covers primary and acute care services (including hospital and post-acute care) and prescription drugs. Medi-

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caid generally covers LTSS, Medicare cost-shar- ing, and some wraparound services not covered by Medicare. Historically, dually eligible beneficiaries were not included in Medicaid managed care programs because of their complex care needs and the lack of financial incentives for insurers to coordinate their care without having the abil- ity to influence both Medicare and Medicaid service use (Kruse, 2014). Had state Medicaid agencies paid for expanded care coordination services and LTSS, any resulting savings would most likely have accrued to Medicare. The result for many dually eligible beneficiaries has been fragmented, uncoordinated care, which, in turn, often leads to reduced access to care, poor care quality, and high costs in the form of avoidable emergency department visits and inpatient stays. Managed care’s ability to provide team- based, integrated care now allows for more effective care coordination for dually eligible beneficiaries who often have complex medi- cal, behavioral health, and LTSS needs. Dually

eligible beneficiaries are being served through three special types of managed care programs, as outlined below. Dual Eligible Special Needs Plans (D-SNP) D-SNPs are a type of MA plan that provides a coordinated Medicare and Medicaid benefit package and offers a higher level of integration than regular MA plans or traditional Medicare fee-for-service. D-SNPs must contract with the Medicaid agencies in the states in which they operate, and in their contracts they must specify a process for coordinating enrollees’ Medicare and Medicaid benefits. This function is impor- tant because it helps reduce the fragmentation and discontinuity of care often experienced by dually eligible individuals in the FFS system. Approximately 1.8 million dually eligible benefi- ciaries are enrolled in D-SNPs (CMS, 2016b). Aligned D-SNP/MLTSS plans States can also use their contracts with D-SNPs to provide Medicare and Medicaid benefits in-

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GENERATIONS – Journal of the American Society on Aging

cluding LTSS and-or behavioral health services. Some states even require that health plans offer a D-SNP in every service area in which they have an MLTSS plan, or vice versa. This poten- tial for aligned enrollment can help to further integration because enrollees would receive all Medicare and Medicaid services from the same health plan. Through the Medicare-Medicaid Financial Alignment Initiative, twelve states are testing either managed fee-for-service or capitated models of integrated care. In the capitated model, a state, CMS, and a health plan enter a three-way contract under which the plan (known as a Medicare-Medicaid Plan) provides seamless and comprehensive coverage for in- tegrated Medicare and Medicaid services in return for a combined prospective payment. Medicare-Medicaid Plans also must provide interdisciplinary care team management to beneficiaries with complex needs. The demon- stration programs will run at least through 2018, and, thus far, they cover approximately 400,000 beneficiaries. The Future of Managed Care In the coming years, managed care programs will continue to grow. Enrollment in MA by 2026 is expected to reach 41 percent of Medicare benefi- ciaries (Jacobson et al., 2016). The enrollment of dually eligible beneficiaries into managed care arrangements is also likely to grow. Plus, the num- ber of states with Medicaid MLTSS programs is increasing. In 2004, only eight states had MLTSS programs (Saucier et al., 2012), but as of 2016, nineteen states have MLTSS programs and two more plan to launch MLTSS programs in 2017 or 2018 (Kruse and Ensslin, 2016). Several related trends are emerging that support managed care’s aim to improve quality and reduce costs compared to the fee-for-service system, as follows: Medicare-Medicaid Plans under the Medicare- Medicaid Financial Alignment Initiative

Rebalancing the Provision of LTSS from Insti-tutional to Community-Based Settings. The growth of MLTSS programs will likely strengthen efforts to rebalance the provision of LTSS from institutional to community-based settings. MLTSS program payment rates can be structured to stimulate care delivery in commu- nity settings (Musumeci, 2015). Addressing Social Determinants of Health. Managed care programs increasingly are recognizing the connection between social deter- minants and health outcomes. While Medicaid programs have typically only paid for direct medical care or services that foster access to care, (including care coordination, interpretation, and transportation), some states are implementing innovative programs that allowMedicaid to pay for a broader range of supportive services, which Community-based providers may be unfa- miliar with how to package and price their services in a way that allows them to contract with managed care plans, health systems, or ACOs. As enrollment of older adults and other higher-need populations into managed care arrangements grows, the U.S. Department of Health and Human Services’ Administration for Community Living has developed a pro- gram to help aging and disability community- based networks to strengthen their partner- ships with the healthcare sector. Through the Business Acumen for Community Based Organizations ( program, eleven networks of community-based aging and disability organizations are participating in a learning collaborative and receiving targeted technical assistance to build their business acumen. Lessons from the learning collaborative will assist other CBOs as they position themselves to enter into agreements with managed care organizations. Building Business Acumen Among Community-Based Providers

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The Field Guide to Managed Care: A Primer

include housing-related services and environ- mental modifications. CBOs can play a key role in ensuring that beneficiaries’ non-medical needs are identified and adequately met. Adopting Value-Based Purchasing Stra- tegies. Adopting value-based purchasing (VBP) stra-tegies that tie payments to performance on quality measures is a major trend in both Medicare and Medicaid, including within their respective managed care programs. VBP arrangements include the following: performance incentives or penalties; shared savings and-or risk against quality and cost targets; episode-based or bundled payments; and global payment programs. Both Medicare and state Medicaid programs will continue to rely on VBP to im- prove the quality of care provided and will turn to managed care organizations to create VBP arrangements with their providers. Conclusion The major shift toward managed care in Medicare and Medicaid is having a profound impact on care delivery for older adults. Larger and larger numbers of individuals with more

complex care needs will be enrolling in man- aged care programs. The focus of these pro- grams on providing integrated, team-based care is pushing the development of new service de- livery models. The shift to managed care also represents a cultural shift for many community- based providers who may feel as if they are entering unfamiliar territory. The good news is that the skills and mission-driven focus of these providers will be a valuable addition to man- aged delivery systems. The challenge is for CBOs to adapt to this culture and develop the business skills to successfully transition into this new environment. Stephen A. Somers, Ph.D., is president and chief exe- cutive officer of the Center for Health Care Strategies in Hamilton, New Jersey. Nancy Archibald, M.H.A., M.B.A, is a senior program/communications officer at the Center for Health Care Strategies. Some states are implementing innovative programs that allow Medicaid to pay for a broader range of supportive services.

References Centers for Medicare & Medicaid Services (CMS). 2016a. Medicaid Managed Care Enrollment and Program Characteristics, 2014. Baltimore, MD: CMS. CMS. 2016b. SNP Comprehensive Report: October 2016 . Baltimore, MD: CMS. Jacobson, G., et al. 2016. Medicare Advantage 2016 Spotlight: Enroll- ment Market Update. Menlo Park, CA: Kaiser Family Foundation.

Saucier, P., et al. 2012. The Growth of Managed Long-Term Services and Supports (MLTSS) Programs: A 2012 Update . Baltimore, MD: CMS. Snyder, L., and Rudowitz, R. 2016. Trends in State Medicaid Programs: Looking Back and Looking Ahead . Menlo Park, CA: Kaiser Family Foundation.

Kruse, A. 2014. Strategies to Facilitate Managed Care Imple- mentation for Medicare-Medicaid Enrollees. Hamilton, NJ: Center for Health Care Strategies. Kruse, A., and Ensslin, B. 2016. State Trends in the Delivery of Medicaid Long-Term Services and Supports. Hamilton, NJ: Center for Health Care Strategies. Musumeci, M. 2015. Rebalancing in Capitated Medicaid Managed Long- Term Services and Supports Pro- grams: Key Issues from a Round- table Discussion on Measuring Performance. Menlo Park, CA: Kaiser Family Foundation.

supplement 1 | 15

GENERATIONS – Journal of the American Society on Aging

Who Cares? Implications of Managed Care for Organizations and the Communities They Serve

By Jennifer Dexter

A more coordinated system will work well, as long as its development includes the voices of people with disabilities, older adults, and providers.

M edicaid, the primary funding source for the majority of long-term services and supports (LTSS) for peo- ple with disabilities and older adults, is changing significantly. Those individuals covered by Medicaid and the service providers supporting them must adjust to ensure that

er adults covered by managed care is a critical issue for organ- izations providing services to these populations. This new demographic is result- ing in a restructuring and reconsidering of business practices, service-delivery models, partnerships, and infrastructure.

myriad, but the primary drivers are states seeking to have a more managed and predictable Medicaid budget and increased incentives to do a better job of providing home- and community- based services under Medi- caid. This evolution includes integrating LTSS with basic healthcare services under a managed care model. According to the National Association of States United for Aging and Disabilities’ (NASUAD) State Medicaid Tracker as of August 2016, twenty-one states are imple- menting managed long-term services and supports (MLTSS) programs and requiring peo- ple with disabilities and older adults to go through a managed

Learning to change thinking and structures to align with MCO needs is a significant issue for providers.

people with disabilities and older adults continue to have access to needed services and supports, including the protec- tion of their entitled rights. The increase in the numbers of peo- ple with disabilities and old-

One of the greatest transfor- mations happening now is that states are rapidly evolving their Medicaid programs to address both increasing need for ser- vices and fiscal constraints. Reasons for this evolution are

abstract States are rapidly evolving their Medicaid programs to address the increasing need for services and fiscal constraints. This transition to managed care in Medicaid, particularly in managed long-term services and supports (MLTSS), requires community-based organizations to have record- keeping and financial systems that can interact with multiple managed care organizations. There will need to be a greater emphasis on partnerships. The LTSS system will also transform to a less special- ized approach. And, there will be a continued and increasing focus on cost containment. | key words : Medicaid, managed care, managed long-term services and supports, community-based organizations

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The Field Guide to Managed Care: A Primer

care organization (MCO) to receive services (NASUAD, 2016). Because they remain under the Medicaid umbrella, most of these waivers require MCOs to deliver a comprehen- sive set of benefits. While this article will focus primarily on the transition to managed care in Medicaid, and particularly MLTSS, there are many ways people with dis- abilities and older adults might be covered by managed care. These include Medicare Special Needs Plans, demonstration programs for individuals dual- ly eligible for Medicare and Medicaid, and Accountable Care Organizations. Many of the opportunities and chal- lenges that the transition to MLTSS offers apply to these other models. MLTSS models, while rel- atively untested to date, offer opportunities for improving care coordination, and-or ex- panding access to LTSS. The following is an overview of some of the effects of transi- tioning to MLTSS. Transitioning to MLTSS One of the bigger shifts when working under managed care is the relationship between the funder and the service provid- er. Under traditional models, providers negotiate a rate and provide a unit of service. This negotiation happens once and may be revisited regularly, based on budgets, but it is a fairly straightforward process.

In a managed care model, ideally there is a partnership between the MCO, the pro- vider, and the individual to coordinate and maximize care, while minimizing costs. This means a need for more regular communication about progress and ongoing needs. MCOs coordinate more aspects of care, and may be looking for partners to provide a complete suite of services instead of having to develop multiple contracts with special- ist provider organizations to create that full array of ser- vices. Learning to change think- ing and structures to align with MCO needs is a significant issue for providers. Teaching MCOs about providers’ experience and

practices is equally important. The experience of organiza- tions like Easterseals is deep— we have a long history of working with people with disabilities and older adults. Taking the knowledge we have about populations we serve and infusing it within the business acumen that MCOs possess can make for a powerful partner- ship. We are known and trusted by the people we serve, and we can help individuals navigate the transition to MLTSS. There is much to be learned from each other. Organizations such as Easterseals understand the impact on outcomes of access to value-added services such as transportation, recreation, respite, employment, and

supplement 1 | 17

GENERATIONS – Journal of the American Society on Aging

caregiver supports. While increasing access to these

ments, the system may not be as efficient or as comprehen- sive as it needs to be and some providers may not be able to provide needed services. What the Transition Means for Clients For individuals covered by MCOs, the best-case scenario is that the change is relatively transparent to them. Compa- rable services to what was available under traditional Medicaid should be available under managed care, with the addition of better care coor- dination. While this has hap- pened for many, other individu- als continue to face challenges accessing care. In actuality, experience is showing that the barriers to accessing needed services are comparable, but slightly different, under man- aged care. People still face uphill battles to get coverage for everything they need, and MCO administration can be difficult to navigate when seeking redress for an issue. There is tremendous opportunity to improve ser- vices for people with disabili- ties and older adults under managed care. With adequate infrastructure and service re- imbursement, there can be a true partnership between the

individual, the provider, and the MCO. And if the system can shift to support new models of service, people will have access to more holistic and coordi- nated care. Time is of the es- sence, though, and MCOs, pro- viders, and individuals must work together to assure all these “ifs” become reality. There also is great risk for people with disabilities and older adults. At the end of the day, the ultimate goal of moving to managed care is to control costs. People with disabilities and older adults often need higher levels of service than the general population. Without protections, services for peo- ple with disabilities and older adults may be limited to man- age costs. Education will be critical in this area. An MCO without experi- ence in early intervention services might not understand that physical therapy for a child with a disability who is working on learning to sit is different than an adult working on the same goal after an injury. For the child, that therapy may result in their ability to sit with- in several years time, while it might be months for an adult. If an MCO sets a cutoff for funding therapy when a goal (like sitting independently) is not achieved after a few months, the child could be denied needed services. This may be due to a lack of under- standing about the needs of a specific population or indivi-

critical services can be difficult to achieve in tight fiscal times, the partnership between MCOs and provider organizations can work to increase access to those services. MCOs are motivated to include these services as preventive measures that will avoid more costly services later. Traditional Medicaid does not offer those incentives.

There will be a continued and increasing focus on cost containment that will require constant vigilance by individuals and providers.

One of the most difficult issues for providers may be interacting with MCO infra- structures. The transition to MLTSS requires community- based organizations (CBO) to have record-keeping and financial systems that can interact with multiple MCOs. While healthcare entities providing acute care have undergone a tremendous transition to electronic health records, a similar transition has not happened for LTSS providers. Providers will need financial and technical assis- tance to create infrastructure that will work in a managed care environment. MCOs are usually supportive in this tran- sition, but in some cases, it can be financially prohibitive for the provider. If there is not some funding for CBOs to sup- port infrastructure improve-

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