Brendan Williams: An attack on New Hampshire long-term care

For the Monitor
Published: 3/19/2018 12:04:26 AM

In 2016, Senate Bill 553 created a working group to study the implications of turning Medicaid for long-term care over to managed care insurance companies – what is referred to as managed long term services and supports, or MLTSS. Ten SB 553 public meetings were held, as well as six sub-group meetings. Last year the Legislature passed a law to delay MLTSS until July 1, 2019.

Now the Legislature has before it competing messages. One is a report from the Department of Health and Human Services, produced six months after the last SB 553 working group meeting, seeking to push MLTSS forward despite no consensus. The report makes unsubstantiated claims to sell MLTSS, such as “increased access to community-based care” and “improved budget predictability.”

No one is gullible enough to believe this. MLTSS has been a disaster elsewhere.

New Hampshire’s nursing home providers are committed to focusing their care on the sickest of the sick. They strongly believe home-and-community-based settings deserve better funding on their own substantial merits.

In increasing “access to community-based care,” states leading the way, like Oregon, realize they don’t need to divert 15 percent of scarce Medicaid resources to support the overhead and profits of insurance companies. In contrast, the MLTSS reality is that insurance companies have routinely delayed, and denied, payment on claims.

In Iowa, the Des Moines Registerreports, “Medicaid expenses for in-home care that had been routinely approved when the state ran the program are now being rejected by managed-care providers as unnecessary.” In New York, Bloombergfound MLTSS discouraged “home-care agencies from accepting high-hours cases and masks the true level of demand.” In Kansas, caregivers are reportedly pressured by insurers to sign off on care plans without seeing them, unwittingly reducing care hours and forcing legal appeals to recover them.

New Hampshire is among states that have, organically, seen long-term care populations re-balance. In December 2017 it had its lowest Medicaid census in nursing homes (4,005 residents), and achieved its highest number of Medicaid home health clients (2,920) in just the prior month. Compared to December 2007 data, this represented an 11 percent drop in nursing home clients and a 14 percent increase in home care clients over a decade’s time.

As to “improved budget predictability,” just last month the General Accounting Office found MLTSS so opaque that even the federal government that oversees it, and funds no less than half of it, could only get complete data from one state out of 20. Illinois, according to a 2018 audit, failed to “adequately monitor” billions of dollars in payments to insurers – even failing to see if they spent what they were legally required to on care. Illinois providers are suing insurers for delayed payments, as are Florida providers.

In a remarkable column (Monitor Forum, March 16), DHHS Commissioner Jeffrey Meyers attacks New Hampshire care, and states 30 percent of nursing homes are “below average or much below average.” Of course they are. If Meyers knew federal law, he would know, according to a February 2018 guide, the federal government “bases five-star quality ratings in the health inspection domain on the relative performance of facilities within a state” and requires no fewer than 20 percent of nursing homes in each state receive a one-star rating – and roughly 23.3 percent receive a two-star rating; only 10 percent can get the highest rating. MLTSS cannot change that. And any one-star building here might be 5-star in another state. In Kansas, nursing home deficiency fines have reportedly gone up 9,000 percent since MLTSS implementation.

Proper MLTSS oversight would require a huge commitment of resources from short-staffed state agencies. In New Hampshire, Medicaid managed care’s initial phase has been beset with cost over-runs. We already spend less on long-term care than almost any other state. Upon what can we base any confidence of lowering long-term care costs by interjecting the 15 percent margins of insurers? Meyers claims the public has “clamored” for MLTSS – a Granite State Poll found only 19 percent of voters supported it. To quote the Marx Brothers, “Well, who ya gonna believe, me or your own eyes?”

The Legislature has before it a straightforward alternative. House Bill 1816 would stop MLTSS and allow the state to focus on real ways of addressing aging in a state with the nation’s second-oldest population. That should include better funding of the entire long-term care continuum, as well as a new program for All-Inclusive Care for the Elderly to potentially provide adult day health for hundreds of residents, a laudable initiative supported by both DHHS and the New Hampshire Association of Counties.

(Brendan Williams is the president/CEO of the New Hampshire Health Care Association.)

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