An update on Managed Long Term Services and Supports (MLTSS)

Millions of Michigan residents need long-term care services because of the disabling conditions of chronic illnesses. Programs like Managed Long Term Services and Supports (MLTSS) meet the needs of those individuals and families through capitated Medicaid managed care programs. Some critics are suggesting MLTSS is the wrong approach for Michigan while trying to draw negative outcome conclusions that don’t exist. On the contrary, national research has found positive outcomes supporting goals of MLTSS such as rebalancing LTSS institutional care to community-based care, improving member experience, quality of life and health outcomes, eliminating waiver waitlists, improving access, budget predictability and managing costs.

Michigan’s current landscape does not fare well for LTSS, according to Across the States 2018 published by the AARP Public Policy Institute Michigan ranks 29th in the nation in the percent of LTSS spent on home and community-based services (HCBS) for older individuals and adults with disabilities. According to the CHRT analysis of Michigan Medicaid Long Term Services and Supports, individuals receiving LTSS made up 5 percent of Medicaid enrollment while accounting for 23 percent of Medicaid expenditures. In addition, Michigan ranks 45th in the country on the percentage of dollars spent on HCBS versus nursing facility care based on FY16 data analysis by IBM Watson Health.

Additionally, there is still a waitlist of approximately 3,500 individuals for the MI Choice program placing these individuals at risk of institutionalization. According to stakeholder interviews and focus groups conducted by CHRT and Public Sector Consultants (PSC), accessing the MI Choice Waiver is “difficult or becoming more difficult” and the waiver cannot serve everyone who is eligible and needs waiver services.

Several states have reduced or eliminated HCBS waiting lists after moving to MLTSS, through mechanisms that include:

• Increased benefit flexibility under managed care (MCOs providing value-added services not otherwise available or providing cost-effective alternatives on a case by case basis)

• A blended capitation rate for nursing facilities and HCBS that incentivizes home and community-based care and provides resources for MCOs to offer more enrollees HCBS

• Earlier identification of needs which allows earlier intervention and prevention of exacerbation that leads to more intensive LTSS needs

MI Health Link has also been attacked by the same critics, indicating that preliminary results of the program are poor. CMS has contracted with the Research Triangle Institute (RTI) for formal evaluations of the state Financial Alignment demonstrations. While there have been early evaluations of some state results, the formal evaluation of MI Health Link is not expected until 2020. However, RTI has reported results of the Quality Withhold Analysis for MI Health Link.

In order to ensure that dually eligible individuals receive high-quality care and to encourage quality improvement, both Medicare and Medicaid withheld a percentage of their portion of the capitation rate paid to each Medicare-Medicaid Plan (MMP). MMPs are eligible for repayment of the withheld amounts subject to their performance on a combination of CMS Core and State-specific quality withhold measures. MI Health Link plans earned 86 percent of the withhold in Demonstration Year 2 (2016).

In December 2018 MDHHS worked with the Center for Health and Research Transformation (CHRT), Health Policy Matters (HPM), and Public Sector Consultants (PSC) to analyze the state’s current long-term services and supports (LTSS) system and review options for expansion of managed LTSS. The research concluded that the MI Health Link program could be a logical platform to adapt for a future MLTSS program due to the infrastructure required to better integrate physical health care, behavioral health care and LTSS. The report also proposed MDHHS request a 3-year expansion of MI Health Link.

The current fragmented LTSS system along with low ranking on the percentage of LTSS dollars spent on HCBS suggests that rebalancing in Michigan would make sense. MAHP supports efforts to implement a MLTSS program that ensures quality of life and positive outcomes to individuals and cost-savings to the State. MAHP is committed to working with the MDHHS and various stakeholders to provide input as the State moves forward with MLTSS efforts.

By Tiffany Stone, Medicaid Policy Director of MAHP