Two weeks ago, members of our team attended the 2015 NASUAD Home and Community Based Services (HCBS) Conference. The conference, focused on in-home care primarily funded through Medicare/Medicaid brought together a diverse set of healthcare players: insurance plan executives, state administrators, nurse care-giver contractors, device vendors and many more. After a multitude of presentations, plenaries, networking sessions, unexpectedly rowdy receptions, and a welcomed long weekend of reflection, here are some stray thoughts from the conference:
This should be painfully obvious, but it’s always worth acknowledging the sheer number of people that toil daily in the mind-numbing logjam that is public healthcare. Many people even inside healthcare would not know the difference between a 1915(c) waiver and a state plan amendment, or why one would want to connect AAAs with the VHA, or how leveraging TEFT grants might be the key to meeting strident eLTSS standards. There are an increasing amount of “fun” healthcare topics to discuss (see gamification or wearables) and almost none of them take center stage in public healthcare. What is in public healthcare are a small amount of people dedicated to serving the sickest, most vulnerable populations against the forces of perpetually fluctuating funding and sporadically invasive oversight.
Could they do better? No question.
But it’s valuable to recognize that railing against the inefficiencies of public healthcare is easier to do when you’re not the one writing multi-hundred page §1115 waiver proposals that then go through rounds of public and private comment to perhaps secure funding approval for a program that citizens medically depend on. Bottom line: working around public healthcare is a thankless job and it’s harder than it looks.
On the first day during an MLTSS intensive, TX HHSC Deputy Director Gary Jessee remarked that attempts at change must be focused, a mantra I heard him repeat several times throughout the conference. Public health lags so far behind the technological capabilities and financial/administrative infrastructure of mainstream healthcare that it’s easy to yearn for large-scale change. But there’s a reason Medicaid and Medicare lag, these are massive entitlement’s responsible for millions of our most medically complex citizens. This isn’t one person contracting with one health insurance plan, or more commonly one employer contracting with one health insurance plan (complexity of these relationships understated for effect). This is every state independently figuring out how to turn dependence on federal funding approval and state legislative approval into real, patient-centered care for their sick, elderly, and disabled populations. The amount of steps between the funding source, CMS, and the delivery of dependable care to, for example, an intellectually/developmentally disabled (I/DD) enrollee truly boggles the mind.
It makes sense then that large-scale change doesn’t happen over night, and even attempting large-scale change can be foolhardy at best. Just ask Tennessee how a swift transition of their full Medicaid population to managed care in 1994 worked out over the following decade. We know that fee-for-service models are undesirable, but in a system burdened by complexity movement is much more realistic with targeted goals. Moving millions of enrollees to managed care is a monumental challenge that requires a coalition of dedicated stakeholders, time, and some degree of political luck. On the other hand, developing systems to provide social services, such as housing, to the medically needy represents a relatively smaller initiative that could have far-reaching effects. While runaway spending characterized TennCare’s initial decade, in recent years the Bureau has become a widely lauded model for providing exceptional service, especially in the areas of housing and behavioral health. For a healthcare environment in which 3–5% of enrollees can account for 50% of spending, such targeted efforts can go a long way.
Which is not to say that focused healthcare initiatives don’t necessitate a coalition of stakeholders; they absolutely do. At these smaller conferences I am always struck by the behind-the-scenes collaboration between groups that seem so combative on the Twitterverse and news outlet headlines. Panels will have state Medicaid administrators next to senior consulting managers next to clinical specialists next to health plan execs next to analytics experts and so on.
As always in public health, a disturbing lack of tech companies.
But while we constantly see headlines touting EHR battles, looming mergers & acquisitions, and competitive RFP bidding, the reality of care on the frontlines of HCBS in public health is relatively tame, if for no other reason than it must be. The aforementioned route from funding origin to care delivery in public health/HCBS/LTSS is excruciatingly complex, and for any stakeholder to ensure proper care AND achieve financial accountability many, many things must go right. Which is why UnitedHealthcare and Amerigroup can needle the TDCI to raise plan rates in the commercial market, but stand next to TennCare’s Director of Elderly and Physically Disabled Services to espouse the merits of wraparound housing services for low-income beneficiaries. It’s why Deloitte and KY state admins were met with audible admiration after detailing their multi-year development of a Medicaid waiver management application that streamlines and digitizes information/processes across a wide array of healthcare services. David Rogers, COO of FL Medicaid asserted that “experience breeds credibility and buy-in” from stakeholders. For any targeted public health intervention, diverse stakeholders have significant incentive to gather, become familiar, and work towards common care and payment delivery goals, even if that collaboration initially seems antithetical. The only way to reconcile and streamline seemingly diverse stakeholder is to get them in a room together.
This brings me to my final reflection, one that gets talked around a lot but never quite said explicitly:
Levels of care assessments are the key point in the long process from funding to care.
It is utterly stunning how often these assessments get mentioned anecdotally as very important but never explicitly delved into by industry participants. The closest I heard to a discussion on this topic was during a panel on participant directed services within managed LTSS services. An audience member asked how plan capitation rates could possibly respond to the fluidity of an LTSS participant’s medical need, to which an Anthem Inc. Senior Director remarked that this could only be possible with accurate and regular assessment processes. Because of course that’s true.
We can think of complex care in public health as a long continuum starting with a source of money and ending with delivery of care. Both the “care” side and the “money” side will fluctuate independently because both are dependent on different factors: the money side dependent on funding decisions and the care side dependent on how much clinical care is both necessary and delivered. However, while they derive direction from separate sources the most efficient allocation of resources will occur when both sides are coordinated and harmonious, when the funding level adequately covers the necessary level of care across variations in need.
The only way to do this is to regularly and accurately assess the need of your enrollees.
This doesn’t mean assess every member every month, of course that would be absurd. But it does mean that when BCBS Tennessee affiliate Shared Health estimated their assessment database to contain over 70 discrete assessments, we find that absurd as well. It means that when the most “innovative” way to assess I/DD enrollees is a paper assessment called the Supports Intensity Scale (SIS) that requires a 12-page case study and a key for the assessor to understand how to complete the scoring algorithms, we wonder whether there might be an easier way. We at Health: ELT would love for more people to consider tech solutions, but having a cogent and specific conversation would be a good start. There were many great sessions at the 2015 HCBS Conference, but a session like that was sorely missed.
As of FY2013, LTSS accounted for almost a third of total Medicaid spending. For the first time ever, a majority ($75B) of the $146 billion spent on LTSS went HCBS over institutional care. I don’t need an AARP study to prove that these services will become centerpieces of national healthcare in the coming years as the baby boomers continue to age. This is a problem for now. If you’re looking for a targeted initiative that will unite diverse stakeholders, make it assessments. Funding and oversight will continue to fluctuate maddeningly. Delivery of care will become more complex. But these two sides of the care continuum will be infinitely easier to handle, less expensive, and more accountable if you really know how much care people need, how much care is being delivered, and how much each of those things costs.