Response of the Massachusetts Senior Care Association to MassHealth’s Dual-Eligibles Request for Information (RFI)

Introduction

The Massachusetts Senior Care Association (MSCA) is a trade association representing more than 500 facility-based long term care providers including skilled nursing facilities, assisted living residences, and hospital-based transitional care units. Our members care for and employ more than 100,000 residents of the Commonwealth. Many of our residents are under the age of 65. In fact, over the past decade, residents under age 65 have been our members’ fasted growing demographic cohort. We have a strong interest in programs for dual-eligibles of any age. Many of our members actively participate in the Senior Care Options (SCO) program for dual-eligibles ages 65 and over and have extensive experience in the integration of Medicare and Medicaid for people with chronic illnesses. We are submitting these written comments in response to MassHealth’s Request for Information (RFI), which was released to interested parties on March 18, 2011. Because we are not a provider or health organization per se but instead represent providers, we will provide input into both Section 4.1 (Interested Parties) and Section 4.2(Providers and Health Organizations) of the RFI. We appreciate greatly the opportunity to comment on behalf of our many members. If you should have any additional questions on our written comments, please don’t hesitate to call Mass Senior Care Senior Vice President W. Scott Plumb at 617-558-0202 or

Responses to RFI Questions

4.1 (1a) What Features of the Integrated Care Entity (ICE) Would Cause Duals to See it as Providing Better Care and Value

The Senior Care Options (SCO) program for duals 65 and over providers us with insight into this question. SCO enrollees appreciate most the service flexibility of senior care organizations and the care management attention they receive. SCOs broaden the range of services beyond that of traditional fee-for-service Medicaid to include dental and vision services, podiatry, minor home modifications such as grab bars, leave of absence payments, extensive use of nurse practitioners, etc. Also, the SCOs seek breadth of provider network over selective contracting arrangements, and this helps attract and retain

enrollees. In addition, the SCOs are able to waive certain artificial hurdles to the provision of quality, integrated care that plague the fee-for-service system such as the three day inpatient hospital stay requirement for Medicare-funded skilled nursing facility care and the growing use of observation stays by acute hospitals (such days cannot be counted toward the SNF qualifying three-day stay). Finally, the voluntary nature of the SCO (enrollees can withdraw at any time) puts pressure on the SCO to be responsive to beneficiary needs.

4.1 (5) Performance Measures

It is important to remember that long term care performance measures are very different from acute and primary care measures. The state’s Medicaid pay-for-performance program for nursing homes, which operated briefly before being temporarily halted due to the state’s budget crisis, looked at a number of quality of care performance indicators germane to long stay residents including percent of residents with physical restraints, UTIs, pressure sores, flu and pneumococcal vaccinations, etc. and quality of life measures such as staff turnover, patient satisfaction scores, falls prevention activities, transition planning, etc. The national Medicare value-based-purchasing pilots are also including measures on preventable hospitalizations. Provider evaluations should include performance measures relevant to the services provided and the population served.

4.1 (8) Organizational Links

Linkages should be established between integrated care entities and nursing facilities as well as community-based organizations. Nursing facilities are in many ways the engine for home and community-based care, discharging back to the community more than 100,000 people a year after they have received successful, short-term post acute care. Information sharing among all providers along the care continuum (acute, primary, post-acute, and long term care) will be crucial to quality care and successful care transitions.

4.2 (5) Would Your Organization Consider Contracting with an Integrated Care Entity (ICE)?

While it is not the only criteria providers would need to weigh before deciding to join an ICE, adequacy of payment would certainly play a major role in the decision. Again, the Senior Care Options model provides insight into this issue. By integrating funding streams and working with providers to limit expensive and unnecessary outcomes such as preventable hospitalizations, Senior Care Organizations (SCOs) are able to use the savings on the acute care side (Medicare) to partially supplement rate inadequacies on the long term care side (Medicaid). SCOs pay nursing facilities fee-for-service Medicaid rates plus 2%. While this is far from a windfall, it does help close the estimated $35/day gap between the average cost of providing nursing facility care and Medicaid fee-for-service payment for that care. SCOs are able to do this because of appropriate reductions in the number of admissions and readmissions to acute care hospitals and other cost savings initiatives. ICEs must be given the same flexibility in setting payment rates for contracting providers as SCOs. Additionally, ICFs should be allowed to create risk-sharing arrangements with contracting providers that encourage high quality and cost effective care. SCOs have encountered difficulty attracting certain skilled nursing facility (SNF) providers because of their aggressive management of the Medicare SNF length of stay (LOS). SCO Medicare LOS averages about one- half to two-thirds of Medicare fee-for-service LOS. ICEs might be encouraged to develop episodic payment arrangements for certain diagnostic categories to mitigate this potential access problem.

4.2 (6a) Community Support Services

Respite care, both community-based and facility-based, should be added to the list of services. With 80% of all long term care provided informally by friends and relatives, respite care is a cost-effective strategy to maximize the quality and quantity of patient care.

4.2 (6b) Incentives to Encourage Care in Home and Community-Based Settings

Unless facility-based long term care services are “carved out” of any integrated, global payment model, it would appear that financial incentives would already exist for providing care in the most appropriate and cost effective setting possible. For some individuals, the most appropriate setting would be their own home or other community-based setting. For others with more specialized and extensive skilled care needs, the setting might well be a skilled nursing facility. Since the proposal emphasizes person-centered care and choice, it is important to remember that choice needs to include all care settings, and not just those that conform to a predetermined “community first” philosophy.

Conclusion

In closing, we are hopeful that this initiative to integrate care for dual-eligible adults ages 21-64 will encourage creativity and flexibility and “outside the box” thinking regarding care delivery and financing systems. The antiquated regulatory environment that promotes “silo” mentalities and inhibits cross-provider system cooperation must be eliminated. The use of nursing facility personnel as back-up caregivers for absent personal care attendants, the use of licensed nurses from SNFs to provide periodic skilled care in home and community-based programs and settings, the elimination of artificial restraints on the efficient provision of health care services such as the prohibition of “post acute only” units in SNFs, the list is almost limitless. As an organization representing providers who care for frail elders and disabled individuals across the care and age continuum, we are eager to participate in the design and implementation of this initiative.

Massachusetts Senior Care Association

April 25, 2011