Jeffrey Meyers: A New Hampshire solution for long-term supports and services

For the Monitor
Published: 3/16/2018 12:20:24 AM

Last week, the New Hampshire Department of Health and Human Services published its proposed plan to incorporate nursing facility and home care services such as personal care into its managed care program. Since December 2013, two managed care organizations, or MCOs, have been delivering primary care and other medical services to about 130,000 Medicaid recipients in New Hampshire.

Last year, the Legislature directed the department to expand the managed care program to include nursing facility and home care services. The department’s plan is a hybrid model that would utilize both MCOs and locally run and regionally based PACE centers – programs for the all-inclusive care for the elderly.

Our plan is the product of a robust stakeholder process begun in July 2016. All those impacted were included in the process: private and county nursing homes, independent case managers, home care providers and beneficiaries. The plan provides real detail on every aspect of the program: covered services, provider credentialing, network adequacy, case management, grievances and appeals and rates and payment. But even with a concrete plan, some providers are pushing back and there is legislation sponsored by Rep. Neal Kurk to prohibit all long-term services and supports from inclusion in managed care.

Why is the department moving forward to deliver and pay for long-term services and supports differently? The short answer is that the Legislature directed the department to do so. But that belies the real rationale: Nursing facility and other long-term care costs are increasing and the performance of too many of our nursing homes is lagging. The current long-term care system for the elderly needs the enhanced care management and financial sustainability that MCOs and PACE centers can provide. Ultimately, we are doing this to allow more seniors to stay in their homes longer and to improve their care once they do need nursing services.

From 2010 to 2018, the cost of nursing facility services paid for by the state has increased from under $180 million a year to $200 million. The counties’ share of that bill – raised from local property taxes – is about half that amount. How high will local property taxes need to be raised as the state’s population – now the second oldest in the nation – continues to age?

Critics of placing nursing facility and home care services into managed care make two arguments: 1) Our state’s nursing homes are highly rated and managed care companies cannot add value, and 2) the current long-term care financing system that relies upon supplemental payments – MQIP and ProShare – cannot be replicated in managed care. Neither of these arguments bears out. Of the 74 private nursing homes rated by the Centers for Medicare and Medicaid Services, 22 (or 30 percent) currently are rated overall with only one or two stars out of a possible five – meaning that they are “below average or much below average.” On quality alone, 19 of those nursing facilities are rated as average or below average. The critics’ claim that there is no room for improvement rings hollow.

The Medicaid Quality Incentive Program, or MQIP, which provides quarterly supplemental payments to nursing facilities for each paid Medicaid bed day, is designed to support nursing facilities that take Medicaid patients. The Proportionate Share Program payments, or ProShare, are annual Medicaid supplemental payments made to county nursing homes to increase their reimbursement to what Medicare would have paid. While these supplemental payments can no longer be made directly to nursing homes by the state under federal managed care rules, the equivalent payment can be paid by the MCO as a “directed payment” that ensures access statewide to these important services. The current financial payment system will be preserved in managed care.

Above all else, the department’s plan offers beneficiaries and providers an alternative to capitated rate managed care delivered by commercial plans: PACE centers. PACE centers around the nation now serve persons 55 years or older who need long-term supports and services. They consist of nursing facilities, home care and medical providers who work together to deliver care. Counties can participate in and even lead a PACE center. PACE centers would be new to New Hampshire and they can and will compete with traditional managed care plans.

The department has listened to those who clamored for a New Hampshire solution to long-term supports and services. Our plan deserves everyone’s careful attention. It will improve quality, care coordination and financial sustainability. And it will provide our citizens real choice.

(Jeffrey A. Meyers is commissioner of the Department of Health and Human Services.)

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