NAP- Neighborhood Alliance of Pawtucket

Aging Studies

LTC Forum presentation at Save the Bay in May 2007

RUNNING HEAD: The Aging Network and Managed Long-Term Care


Larry Polivka, Ph.D.1

Helen Zayac (Doctoral Candidate)2
















Direct correspondence to:
Larry, Polivka, Ph.D. 813-974-3468 (phone)
School of Aging Studies, College of Arts and Sciences 813-974-5788 (fax)
Florida Policy Exchange Center on Aging lpolivka@cas.usf.edu (e-mail)
University of South Florida
13301 Bruce B. Downs Blvd., MHC 1341
Tampa, FL 33612



1School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida
(see above note for contact information)
2School of Aging Studies, Florida Policy Exchange Center on Aging, University of South Florida
13301 Bruce B. Downs Blvd, MHC 1305, Tampa, FL 33612, Phone: 813-974-9439,
Fax: 813-974-5788, e-mail: hzayac@cas.usf.edu

Abstract

Since the early 1980s, area agencies on aging and service providers (the aging network) have developed a number of strengths as they built a community-based long-term care system in most states. Many area agencies and providers now have the capacity to assess the needs of older persons, identify appropriate services, and administer cost-effective community programs, while operating within fixed, capped budgets. They have also been able to identify and maintain roles for informal caregivers, draw on community resources through donations and the use of volunteers, and create substantial political support. In this paper we argue that the aging network should draw on these strengths to develop integrated long-term care systems designed to shift the balance of state long-term care systems from institutional to home- and community-based services. We also argue that the non-profit aging network (area agencies on aging and service providers) provides a potentially more effective framework for the integration of long-term care resources than proprietary managed care organizations.
Key Words: social capital, services integration, Medicaid, community care, cost effectiveness


Introduction
Over the last 20 years, many states have made improvements in their long-term care systems for the elderly by funding private and public non-profit aging services providers to provide home- and community-based alternatives to nursing home care. An accumulating body of research tends to indicate that these community programs are, on the whole, relatively cost-effective in comparison with nursing home care, which now costs $60,000 or more annually in most states (Grabowski, 2003; Wiener and Lutzky, 2001a, 2001b; Wiener, Tilly and Alecxih, 2002 ). Most states, however, are still spending 70 to 80 percent of their long-term care funds for the elderly on nursing facility care (Kaiser, 2006). Relatively few states have achieved balanced long-term care systems that are responsive to the overwhelming preferences of the frail elderly for community-based care (Wiener, 2006).
In our judgment, the aging network represents an extraordinary, though underutilized, resource for creating more balanced long-term care systems through the expansion of home- and community-based services. The aging network includes state aging offices, 665 area agencies on aging, approximately 240 tribal organizations, thousands of non-profit, home- and community-residential service providers, and monitoring and advocacy groups like nursing home ombudsmen. In building community-based long-term care systems over the last 25 years, area agencies on aging and service providers have developed a number of strengths, including the ability to assess the needs of older persons, identify appropriate services, and administer cost-effective community programs, while operating within fixed, capped budgets. They have also been able to identify and maintain roles for informal caregivers and draw on community resources through donations and the use of volunteers.
In this paper we argue that the aging network should use these resources to begin the development of integrated long-term care systems designed to shift the balance of state long-term care systems from institutional to home- and community-based services. We also argue that the non-profit aging network (area agencies on aging and service providers) provides a potentially more effective framework for the integration of long-term care resources than proprietary managed care organizations. The paper is divided into three sections, beginning with a discussion of the value of an integrated approach to long-term care financing and service delivery. The second section describes managed long-term care strategies and includes a brief review of the relatively small body of research on managed long-term care programs. In the third section we offer our rationale for an aging network-based approach to managed long-term care.
Integrating long-term care financing and service delivery
Arguably, the principal lesson to be drawn from the experiences of the few states with relatively balanced long-term care systems is that methods of organizing the financing and delivery of long-term care are critical. Reports on state long-term care policies and practices over the last ten years indicate that the integration of administrative and policy responsibility for long-term care under a single administrative authority at the state level, with access to services through single-entry systems at the local level, may be essential to the creation of organizational environments for balancing state long-term care systems (Alecxih, Lutzky and Corea, 1996; Administration on Aging, 2005; Fox-Grange, 2006; Kane, Kane, Kitchener, Priester and Harrington, 2006).
In their analysis of efforts in eight states to create a more balanced long-term care system by expanding community-based programs, Kane, Kane et al. (2006) found considerable variation in approaches, as well as emerging trends that tend to support organizational integration. These trends include greater articulation of all Medicaid and state funded long-term care programs, program integration across multiple consumer groups, and more centralization of statewide long-term care functions. These organizational initiatives are designed to achieve a greater “. . . focus on the shared goals of rebalancing to pinpoint accountability for outcomes, and to render budgetary allocation and reallocation more flexible” (p. 18).
The authors conclude with the observation that the most effective arrangement for creating a more balanced long-term care system featuring the continuous expansion of community-based programs appears to be:
“. . . a situation where the same entity responsible for operations develops the forecasting or fiscal analysis on which the budget allocations are based and, moreover, has the ability to move money between institutional budgets and HCBS budgets, across programs, and across consumer groups. (p. 18)
In most states, the management of long-term care programs is split between departments of aging/senior services (home- and community-based programs) and the departments housing the Medicaid program (nursing homes). Only three states (Oregon, Washington, and Vermont) have fully integrated control over all long-term care programs and funds, including the Medicaid Nursing Home Program, in a single state aging agency. The department that houses Medicaid, in effect, controls on average 70 to 80 percent of all long-term care resources. Most states need to make changes in their organizational and administrative structures and the ways they control the use of resources before they can create a more integrated long-term care system designed to take full advantage of all long-term care resources and better serve the interests of the long-term care consumer.
A managed long-term care approach to long-term care integration
An alternative method of integrating long-term care authority that does not require a single state agency with complete control over policy and all long-term care funds is to develop a managed long-term care program at the local or regional level and operate it under a capitated rate with funds from all sources, including Medicaid nursing home and general revenue funds. Saucier, Burwell, and Gerst (2005) describe part of the rationale for managed long-term care strategies by pointing out that:
Long-term care users need a variety of services across numerous settings (e.g., home, doctor's office, hospital, day center, nursing home), but in the Medicaid and Medicare fee for service systems, no single person or organization is responsible for or can impact all needed care, resulting in services that are often characterized as fragmented, uncoordinated and rife with unintended financial incentives. State home-and community-based services (HCBS) programs almost always provide case management, but the management does not extend into the hospital or nursing home when someone is admitted. Often, a community case manager learns about a hospital discharge after the fact, with no ability to ensure a smooth transition across settings. Avoidable hospital admissions, unnecessary use of nursing home care, and education mismanagement are among the risks faced by the population. [This is why.] The application of managed care strategies to aged and disabled long-term care beneficiaries holds intrinsic appeal. (p. 2)
This appeal notwithstanding, managed long-term care programs have developed slowly over the last 15 years; the first managed long-term care program was the Medicaid Arizona Long-Term Care System (ALTCS) which began in 1991. ALTCS operates statewide and is still the largest managed long-term care (MLTC) program in the country with over 24,000 participants. The Minnesota Senior Health Options (MSHO) and Massachusetts’ Senior Care Options (SCO) programs are the only other statewide MLTC programs. Unlike the ALTCS program, these two programs are designed to operate under a Medicaid/Medicare blended capitation rate which supports the integration of acute and long-term care services. This approach to the financial integration of Medicaid and Medicare was first implemented in the Program of All Inclusive Care for the Elderly (PACE) and the Social HMO program in the early 1990s (Branch, Coulam and Zimmerman, 1995; Kane, Kane, Finch et al., 1997; Stevenson, Murtaugh, Feldman et al., 2000). Several other MLTC initiatives have emerged over the last several years, the most prominent of which are the Texas Star Plus Program, The Florida Diversion and Elder Care Programs, the Wisconsin Family Care and Partnership Programs, and 15, relatively small, MLTC programs in New York. Although these programs serve a small percentage of all those receiving long-term care services (about 3 million), the movement toward MLTC appears to be gaining force with the development of the MSHO and Massachusetts SCO programs, and plans to expand the Texas Star Plus, Florida Diversion, and Wisconsin Family Care programs.
These programs very considerably in terms of target populations, the range of funding sources in addition to Medicaid included managed care programs, geographical scope, benefit packages, voluntary vs. mandatory participation of eligible populations, and protection of traditional, non-profit providers, which has been a major concern of aging network advocates in most of the states with MLTC initiatives. For example, Saucier et al. (2005) report that:
[In Wisconsin,] When the State Department of Health and Family Services released its plan for long-term care reform based on the Partnership model of fully integrated acute and long-term care, aging and disability advocates organized strong opposition at a series of public hearings. They were concerned that integrated plans would be dominated by medically oriented HMOs, and the aging network would lose its role in the system. The Department withdrew its plan, and the Family Care program was developed instead, featuring a prominent role for counties and limiting the program to long-term care. In Massachusetts, a network of Aging Services Access Points (ASAPs) serves a number of roles. Several are designated Area Agencies on Aging, and several are providers of care coordination, home care, and other long-term care services. . . . In Florida, certain long-term care providers are statutorily eligible to become diversion program contractors by virtue of their state provider licensure status. (p. 12-13)
Managed long-term care programs also vary in terms of the kinds of organizations administering the programs. Proprietary organizations have begun to participate more extensively in MLTC programs, especially in Texas, Florida, Arizona, and Massachusetts, where relatively large MLTC initiatives are underway.
The evaluative research on MLTC is not yet extensive enough to determine precisely the relative cost-effectiveness of managed care vs. fee-for-service long-term care programs or of different managed care strategies. Some of the findings, however, from these initial studies suggest that MLTC has substantial potential to increase service efficiency and expedite the shift to a more community-based long-term care system. An evaluation study by Weissert, Lesnick, Musliner and Foley (1997) of the Arizona Long-Term Care System (ALTCS) found that the state had substantially reduced nursing home use by expanding the availability of Medicaid funded home- and community-based services through the MLTC program. Overall, the authors concluded that the expansion of community-based services helped enrollees avoid over 270,000 nursing home days and saved the state an estimated $4.6 million.
An evaluation (Mitchell, Salmon, Polivka and Soberon-Ferrer, 2006) of Medicaid waiver-funded HCBS programs for the aged in Florida found that they were bracketed by the state’s two managed long-term care programs in terms of relative cost-effectiveness with the three fee-for-service programs in between. The Frail Elderly Program was the most cost-effective and the Diversion Program, with a much higher capitation rate, was the least cost-effective, when controlling for a wide range of participant characteristics.
A recent evaluation of the Wisconsin Family Care Program (APS Healthcare, Inc., 2005) found that the program has generated significant savings and changed the kinds of services provided. The program is administered by county aging service agencies in the five project counties. The Milwaukee county agency is also the Area Agency on Aging. The Family Care Program serves over 10,000 Medicaid eligible elderly, disabled, and developmentally disabled persons and is operated through two major components—aging and disability resource centers and care management organizations. The resource centers serve as single points of entry into the long-term care system, providing information, counseling, and access to all long-term care services, and information on providers, preventive health care, and early intervention services.
The Care Management Organizations (CMOs) are county-based managed care organizations that receive capitated payments for all long-term care services, including nursing home care. The capitation rate includes Medicaid (nursing home and home- and community-based services), state, and county funds consolidated into single monthly payments that average about $1,800 a month. The capitation rate constitutes a strong incentive to keep consumers in the community by minimizing nursing home care costs and to create a seamless system in which individuals’ needs dictate the services provided, rather than program eligibility criteria (Wiener, Tilly, Alecxih and Mario, 2002). Findings from the evaluation indicate that the Family Care CMOs purchased (or prompted their members to purchase, in the case of primary and acute care) more of some lower-cost services and less of other higher-cost services, with the result that the cost of the total package was lower for the Family Care members than for a matched comparison sample of individuals receiving Medicaid-funded services who were not in the Family Care Program. For example, average individual monthly costs at the end of the study period for a Milwaukee County frail elder’s care in a community-based residential facility (CBRFs) was $462 more than that spent for CBRF care for the comparison group. On the other hand, average individual monthly costs for nursing facility care of frail elders served by the Milwaukee CMO were $1,363 less than those for frail elders in the matched comparison group at the end of the study period. These shifts in services are a direct result of the flexibility in managing resources through the Family Care benefit package.
Rationale for aging network-based managed long-term care
Several factors are likely to make managed care approaches to the integration of long-term care finances and services increasingly appealing to state policy makers interested in making their long-term care systems more efficient and consumer-oriented. The potential administrative and consumer benefits of integrating long-term care finances and the growing need for long-term care services are likely to make MLTC strategies increasingly attractive to policy makers who are already familiar and comfortable with the extensive role played by proprietary managed care organizations in the Medicaid acute care programs in most states. In order to compete in this emerging scenario, aging network organizations will need to prepare their own MLTC proposals and advocacy campaigns, drawing on the capacities they have developed in providing community-based care for over 30 years with general revenue, consumer fees, and Medicaid HCBS waiver funds.
Policy makers also have a role to play in preserving the private, non-profit agencies’ roles in long-term care by having the state share risk with them during the first three-to-five years of operation. This risk-sharing arrangement was part of the Wisconsin Family Care program during the program’s first three years, but the agencies managed their budgets well enough to avoid having to rely on it. This would seem to be a fair provision, given the legal prohibition against the accumulation of large capital reserves by private, non-profit (501.3) agencies.
In addition to their demonstrated capacity to administer long-term care services, the potential value of a non-profit aging network-based approach to managed long-term care is indicated by a recent article (Schlesinger and Gray, 2006) on the roles of not-for-profit and for-profit health care organizations in the American health care system. The authors reviewed 275 empirical studies covering a wide range of services, including hospital, nursing home, home health, hospice, and managed care plans. These studies examined several attributes of services, including cost, quality, and accessibility to indigent clients, trustworthiness of organization practices, pricing policies, and stability of service provision over time. The authors found that attributes were consistently related to ownership type. For-profit organizations more aggressively mark up prices over costs and otherwise maximize revenue. Non-profit organizations appear more trustworthy in delivering services, being less likely to make misleading claims, to have complaints lodged against them by patients, and to treat vulnerable patients differently from other clientele. Non-profits are typically the incubators of innovation (for example, health maintenance organizations, or HMOs, during the 1930s or hospice three decades ago), using philanthropy and cross-subsidies (social capital) to finance the development of services for which there is not yet a market. These three consistent differences constitute advantages for non-profits.
The fourth major difference is that non-profit health care providers are slower to react to change, expanding capacity less quickly when demand rises and dropping services or withdrawing from markets less frequently when profitability declines. This last attribute would appear to favor for-profit providers. The authors, however, express considerable ambivalence about whether this apparent advantage works well for patients.
Providers that constantly alter their service mix or market areas can disrupt vital relationships between patients and providers, and changing insurer practices can undermine patients’ financial security. Recent experience with private health plans in the Medicare+Choice program illustrates such concerns. Frequent plan withdrawals and unstable benefits—both more pronounced among for-profit plans—left millions of seniors confused, without medical care, and with uncovered expenses. (Schlesinger and Gray, 2006, p. 298)
Preserving and strengthening the role of non-profit agencies in long-term care may be even more important than maintaining their presence in the acute care system for the reasons described by Schlesinger and Gray (2006). More important, because long-term care is labor intensive and, at its best, depends on close interaction between formal (paid) and many forms of informal (unpaid) care provided by family members, friends, neighbors, and members of voluntary organizations, including churches. This caregiving network is more likely to thrive under the leadership of non-profit, mission-driven organizations than for-profit organizations with a primary focus on generating shareholder value. The social capital (community trust and support) of non-profit organizations, is essential to building and maintaining networks of formal and informal care that are increasingly important in meeting the growing need for both privately and publicly supported long-term care services. The social capital of the non-profit agencies in the aging network is critical in meeting (The President’s Council on Bioethics, 2005) the potential crises of caregiving:
The first is the danger that some old people will be abandoned or impoverished, with no one to care for them, no advocate to stand with them, and inadequate resources to provide for themselves. The second danger is the complete transformation of caregiving into labor, creating a situation where people’s basic physical needs are efficiently provided for by “workers,” but their deeper human and spiritual needs are largely ignored. (p. 48)
The risk of abandonment is likely to grow along with the large population of baby boomers who will not have children or spouses to help provide care. Furthermore, recent research indicates that individual social networks, including friends and family members, have declined sharply over the last 20 years (McPherson and Smith-Lovin, 2006). These trends indicate that the frail elderly of the future will be increasingly dependent on community support. Communities will be pressed to generate the levels of social capital that will be required to prevent the abandonment of those older persons who cannot pay for their own long-term care. The danger of commodifying long-term care is more likely to be avoided if the non-profit, ethic of care-oriented aging network is able to survive and play a more comprehensive role in the delivery of long-term care services.
In making the case for an HMO-based approach to MLTC, Saucier and colleagues (2005) raise a number of what they call “supply side issues” that need to be addressed in order to make long-term care an attractive investment opportunity for proprietary managed care organizations. According to the authors, these issues need to be resolved in a manner designed to reduce the role of local provider-sponsored MLTC plans in order to create more opportunities for proprietary MCOs. This perspective is contrary to our view that aging network-based organizations (local providers) should play a major role in MLTC. The authors state that:
In some states, providers have applied political pressure directly to legislatures to ensure a role in a managed care program. In other states, the implementing agency deliberately creates a role for provider-based plans to ensure that traditional infrastructure does not evaporate, to attract an adequate supply or to take advantage of the long-term care expertise in those provider organizations. The challenge is to regulate entities that generally have very little experience managing risk and very little capital to establish reserves. Continued reliance on provider-sponsored plans may result in the market being dominated by many small plans with low enrollments.
. . . venture capitalists are more interested in developing managed long-term care products that can be more easily replicated across states. Managed long-term care programs that are so state-specific that they cannot be leveraged in other markets will not be as attractive to investors. (p. 25-26)
Small plans with relatively low enrollments may not generate all of the economies of scale advantages that presumably accrue to large, multi-state plans, but small not-for-profit agency administered plans offer advantages that we think are more important. These advantages include the capacity to reinvest savings (profits) in local or regional long-term care services and greater responsiveness to the unique characteristics (strengths and needs) of local long-term care systems, which is essential to generating and effectively utilizing social capital. Furthermore, local aging network-based plans may be able to collaborate with contiguous local plans to create larger, regional plans with enrollments large enough to achieve significant economies of scale in their operations without forfeiting their embeddedness in local communities.
The authors also question the viability of county-based, aging network-based models of MLTC. They state: “While county-based plans appear to be viable suppliers in states with a history of county involvement, their further development remains local by definition and does not increase the number of suppliers who are active on the national market (Saucier et al., p. 26).”
This observation, like the one quoted above, raises the question of what the appropriate scale for long-term care systems should be and the kinds of organizations that are best prepared to administer appropriately scaled systems? The fact that national MCOs are primarily interested in developing multi-state, uniformly structured MLTC systems does not mean that this should be the primary policy goal of policy makers and long-term care advocates. As we have noted, long-term care systems should be as integrated (embedded) into local and regional communities as possible; community embeddedness should be a more important criterion in determining the scale of long-term care systems than the proprietary interests of large MCOs. We should also not lose sight of the fact that community embeddedness and the potential it creates for the generation of social capital helps protect local and state-specific long-term care systems against the unpredictable and often:
. . . abrupt Medicaid policy changes that can occur, especially during periods of state fiscal stress. Third, there is no assurance that this market will grow to a mature level, given its history to date. We are not likely to see more national companies venturing into this market until there is a significant increase in demand from states. (Saucier et al., p. 26)
This fundamental reality of Medicaid funding and reimbursement policy creates considerable uncertainty in long-range profitability and the always present possibility that proprietary MCOs would exit the long-term care market, leaving only locally or regionally administered community-embedded long-term care programs, if they still exist.
Conclusion
Many state aging service units, area agencies, and providers may be reluctant to take control and responsibility for all long-term care services through the kind of managed care approach represented by the Wisconsin Family Care Program. Aging networks differ in their capacities to undertake the kinds of organizational and financial management tasks inherent in a managed long-term care initiative (Nadash and Ahrens, 2004). Nonetheless, it is time for national aging organizations, state units, and area agencies to use information generated by the Wisconsin Family Care programs and other managed long-term care programs to move toward the goal of establishing statewide, integrated long-term care programs within the next ten years. This does not mean that all long-term care funds should invariably be integrated into a single capitated fund. States may decide to include only Medicaid funds (nursing home and community program funds) in a single, integrated fund and use their general revenue and Older Americans Act (OAA) funds to support early intervention and prevention-oriented services for a broader population of consumers than just those who are Medicaid eligible.
Managed long-term care may not be a fully adequate substitute for the kind of integrated organizational structures that Oregon and Washington use to administer all phases of their long-term care systems and which have played a critical role in both states’ largely successful efforts to create well-balanced (HCBS and nursing home care) systems of long-term care. It does not appear, however that many more states are prepared to implement similar systems of consolidated administration any time soon. In the absence of administrative consolidation of managed care strategies, Wisconsin Family Care represents a promising alternative approach to creating organizational vehicles for merging resources, integrating administrative authority, removing program barriers and providing services in a manner more consistent with consumer preference and choice.
Changing the direction of long-term care will be difficult. The task, however, of creating a more consumer-oriented community-based long-term care system will not be as difficult, either politically or fiscally as trying to maintain the current system for another 20 years. If the aging network in communities across the country does not use its unique resources to create a mission-driven, ethic of care-oriented approach to integrating long-term care services and expanding access to home- and community-based care, for-profit managed care organizations are likely to take the lead in the development of comprehensive, capitated systems of long-term care.
The Special Needs Program (SNP) created by the Medicare Modernization Act provides a potentially strong incentive for Medicare managed care organizations (Medicare Advantage) to incorporate long-term care services for the Medicaid/Medicare dually eligible population. The success of the SNP probably depends on the ability of Medicare MCOs to convince many more dually eligible beneficiaries to join their plans. They must also convince state Medicaid officials and policy makers that Medicare costs will not be contained by shifting them to Medicaid. These are significant challenges to the development of the program on a wide scale. The program, however, is conceptually appealing and a clear indication that health care integration is becoming a federal priority (Gold, Hudson and Davis, 2006). It is also an indication that the aging network needs to step up its efforts to create its own integration strategies, including managed long-term care, or risk becoming marginalized in the development of new approaches to long-term care financing and service delivery over the next several years.

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